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THE  HEART  AND  THE  AORTA 


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PUBLISHED  ON  THE  FOUNDATION 
ESTABLISHED  IN  MEMORY  OF 

WILLIAM  CHAUNCEY  WILLIAMS 

OF  THE  CLASS  OF  1822,  YALE  MEDICAL  SCHOOL 
AND  OF 

WILLIAM  COOK  WILLIAMS 

OF  THE  CLASS  OF  1850,  YALE  MEDICAL  SCHOOL 


THE 

HEART  AND  THE  AORTA 

STUDIES  IN  CLINICAL  RADIOLOGY 

BY  H.   VAQUEZ 

Professeur  agrege  a  la  Faculte  de  Medecine  de  Paris 
Medecin  de  l'Hopital  Saint-Antoine 

AND  E.   BORDET 

Chef  de  laboratoire  adjoint  a  la  Faculte 
de  Medecine  de  Paris 

TRANSLATED  FROM  THE  SECOND  FRENCH  EDITION 
BY  JAMES  A.   HONEIJ,   M.D.,  AND  JOHN  MACY,  M.A. 

WITH  181  ILLUSTRATIONS 


NEW  HAVEN 
YALE  UNIVERSITY  PRESS 

LONDON  •  HUMPHREY  MILFORD  •  OXFORD  UNIVERSITY  PRESS 

MDCCCCXX 


COPYRIGHT,  1920,  BY 
YALE  UNIVERSITY  PRESS 


THE  WILLIAMS  MEMORIAL 
PUBLICATION  FUND 

THE  present  volume  is  the  fourth  work  published  by 
the  Yale  University  Press  on  the  Williams  Memorial 
Publication  Fund.  This  Foundation  was  established 
June  15,  1916,  by  a  gift  to  Yale  University  by  Dr.  George 
C.  F.  Williams,  of  Hartford,  a  member  of  the  Class  of 
1878,  Yale  School  of  Medicine,  where  three  generations 
of  his  family  studied — his  father,  Dr.  William  Cook 
Williams,  in  the  Class  of  1850,  and  his  grandfather,  Dr. 
William  Chauncey  Williams,  in  the  Class  of  1822. 


PREFACE  TO  THE  SECOND  EDITION 

THIS  book  has  been  received  with  such  favor  by  the 
medical  profession  that  the  first  edition,  published  in 
1913,  was  quickly  exhausted.  We  have  decided  to  reprint 
it,  notwithstanding  the  material  difficulties  which  can  well 
be  imagined.  We  have  taken  this  opportunity  to  modify 
some  chapters  and  to  add  new  ones,  dealing  with  the 
measurement  of  cardiac  hypertrophy  by  finding  the  index 
of  depth,  with  the  diagnosis  of  pulmonary  and  tricuspid 
insufficiency,  and  finally  the  localization  of  projectiles  of 
war  in  the  heart  and  the  pericardium.  We  have  tried  to 
keep  in  this  work  the  practical  value  which  physicians 
have  recognized  in  the  first  edition  and  more  especially 
for  those  who,  having  the  task  of  drawing  up  the"  dossiers 
de  reforme"  for  soldiers  afflicted  with  cardiac  affections, 
wished  to  add  to  the  indications  of  current  semeiology 
the  more  precise  indications  of  radiological  methods. 

February,  1918. 


PREFACE  TO  THE  FIRST  EDITION 

r¥^HE   semeiology  of  the  cardio-vascular  system  has 
I    been  considerably  enriched  by  adding  graphic  record- 
ing and  radiology  to  the  old  methods  of  examination,  such 
as  percussion,  palpation,  and  auscultation. 

Graphic  recording  has  enabled  us  to  analyze  with  pre- 
cision the  mechanism  of  the  cardiac  rhythm,  to  distin- 
guish its  different  anomalies,  and  to  refer  to  arhythmic 
actions  their  place  in  diagnosis  and  prognosis  of  diseases 
of  the  heart  so  important  and  long  misunderstood. 

More  recently  radiology  has  come  to  take  a  place  beside 
graphic  recording,  the  importance  of  which  is  continually 
increasing. 

At  the  end  of  the  last  century  it  was  not  believed  that 
the  field  of  roentgenological  exploration  would  ever  pass 
beyond  the  domain  of  surgery.  If  we  considered  radiog- 
raphy perfectly  capable  of  determining  the  exact  lesion 
in  the  bones,  wTe  thought,  on  the  other  hand,  that  it  was  of 
doubtful  value  in  the  examination  of  the  internal  organs. 
To  determine  the  relation  of  the  lungs  and  the  heart  in 
the  different  pathological  conditions,  to  judge  the  state 
of  the  pulmonary  parenchyma,  to  give  a  rough  estimate 
rather  than  a  measurement  of  the  volume  of  the  heart, 
was  all  that  we  then  expected  of  radiography.  It  did  not 
seem  that  it  could  ever  accomplish  more. 

Progress  of  inestimable  value  has  been  made  in  precise 
radiology  which  enables  us  to  obtain  normal  images  of 
the  heart  according  to  the  plane  of  projection  or,  to  state 
it  better,  the  exact  configuration  and  the  true  contours  of 
that  organ.  In  the  pathological  state  this  configuration 
and  these  contours  undergo  variable  modifications,  but 
in  direct  relation  to  organic  alterations  of  the  heart.  It 
follows,  then,  that  we  have  a  right  to  diagnose  the  lesion 
with  which  the  heart  is  affected,  upon  a  simple  examina- 
tion of  its  exterior  aspect.    This  notion,  well  established 


xii  PREFACE  TO  THE  FIRST  EDITION 

by  anatomical  proofs,  has  been  until  our  day  only  imper- 
fectly utilized  in  clinics,  the  processes  of  exploration 
being  incapable  of  giving  sufficiently  precise  indications. 

Eadiology  of  precision  has  come  to  fill  this  gap.  Dur- 
ing the  life  of  the  patient  it  shows  to  the  observer  the 
heart  as  it  appears  on  post-mortem  examination,  perhaps 
even  less  deformed,  for  it  is  animated  by  the  circulation. 
Eadiology  gives  a  precise  objective  description  of  patho- 
logical deformations  and  reveals  the  exact  exterior  con- 
figuration of  the  heart,  which  warrants  our  concluding 
the  existence  of  different  organic  or  valvular  lesions. 

In  spite  of  their  importance,  the  data  relating  to  these 
examinations  have  not  yet  in  France  been  made  the  sub- 
ject of  a  complete  work.  It  seemed  to  us  therefore  that 
it  would  be  interesting  to  gather  together  ideas  which 
have  been  scattered  and  to  add  to  them  the  result  of  our 
personal  observations. 

It  is  not  our  purpose,  however,  to  issue  a  didactic  trea- 
tise on  radiology  of  the  heart  and  the  aorta,  so  the  reader 
will  not  find  the  profusion  of  bibliographic  references, 
citations,  and  names  of  authors  which  he  might  reason- 
ably expect  in  a  work  of  this  kind. 

Although  we  are  compelled  to  tell  what  we  have  ob- 
served and  indicate  the  methods  used,  we  have  also  set 
forth  the  results  arrived  at  by  certain  authors  who  have 
preceded  us.  When  our  opinion  has  agreed  with  theirs 
we  have  not  failed  to  mention  it.  When  we  have  differed, 
we  have  given  the  reasons,  indicating  the  grounds  for  our 
conclusions. 

The  work  which  we  present  today  to  the  medical  pro- 
fession may  be  useful  to  radiologists,  who  will- find  here 
the  description  of  the  mechanical  methods  which  we  have 
used,  as  well  as  to  physicians  to  whom  it  will  furnish 
indispensable  ideas  about  a  method  of  exploration,  a 
knowledge  of  which  appears  more  and  more  necessary. 

H.  Vaquez  and  E.  Bordet. 


TABLE  OF  CONTENTS 


PAGE 

Preface  to  Second  Edition ix 

Preface  to  First  Edition xi 

CHAPTER  I 
Radiological  Methods 

I.     Radiographic  methods 2 

1.  Time  radiography 2 

2.  Instantaneous  radiography 3 

3.  Teleradiography 3 

II.     Radioscopic  methods 4 

1.  Normal  radioscopy 4 

2.  Orthodiascopy 5 

3.  Orthodiagraphy 7 

4.  Teleradioscopy         11 

III.  Personal  technic 11 

IV.  Comparison  of  methods 12 

CHAPTER  II 
Normal  Heart  Shadow 

I.     Positions  of  patient — Definitions 16 

1.  Direct  positions 16 

2.  Oblique  positions 18 

3.  Lateral  positions 18 

II.     Study  of  heart  images  in  the  principal  positions  .      .  18 

A.     Heart  image  in  frontal  position       ....  18 

Contours 20 

Apex  of  the  heart 23 

Measurements  of  shadow 23 


xiv  CONTENTS 

PAGE 

Mobility  of  heart 33 

Displacements  due  to  respiration       ...  34 

Heart  pulsation 36 

B.     Image  of  the  heart  in  oblique  positions       .      .  38 

Right  posterior  oblique  position  ....  38 

Left  posterior  oblique  position     ....  43 

Right  anterior  oblique  position     .      .      .      .  44 

Left  anterior  oblique  position       ....  45 

Lateral  positions 47 

III.  Variations  of  the  physiological  form  of  the  heart       .  50 

IV.  Particular  studies  to  determine  ventricular  develop- 

ment in  depth 53 

V.     Summary  and  conclusions  to  follow  in  radiological 

examination  of  heart 58 


CHAPTER  III 

Heart  Shadow  in  Pathological  State 

Modifications  affecting  the  whole  heart     ......  61 

Partial  modifications 63 

I.     Determination  of  total  ventricular  volume     .  64 

II.     Left  ventricle 66 

III.  Right  ventricle 68 

IV.  Left  auricle .  71 

V.     Right  auricle       .      .      .      .      .      .      .      .      .  72 


CHAPTER  IV 

Valvular  Affections 

Simple  mitral  stenosis 75 

Examinations  in  direct  anterior  position     ...  75 
Interpretation  of  cardiograms  and  comparison  with 

percussion 80 

Examination  in  oblique  positions 82 

Mitral  insufficiency 87 

Functional  mitral  insufficiency 93 

Mitral  disease 96 


CONTENTS  xv 

PAGE 

Aortic  insufficiency 102 

Endocarditic  aortic  insufficiency 102 

Aortic  insufficiency  of  arterial  origin 108 

Aortic  stenosis Ill 


CHAPTER  V 

Congenital  Affections  of  the  Heart 

I.     Stenosis  of  pulmonary  artery  with  inter-ventricular 

perforation 115 

II.     Simple  stenosis  of  pulmonary  artery 123 

III.  Inter-ventricular  perforation 127 

IV.  Congenital  aortic  stenosis 132 

V.     Cardiac  ectopia  and  total  inversion  of  the  viscera     .  131 

CHAPTER  VI 

Radiological  Outline  of  Heart  in  Certain  Pathological 
Conditions  not  Resulting  from  Valvular  Lesions 

I.     Cardiac  hypertrophy  and  dilatation 142 

II.     Cardiac  hypertrophy  in  the  aged     .      .      . .    .      .      .  146 

III.  Cardiac  dilatation 148 

IV.  Basedow's  disease • 152 

V.     Arhythmic  heart 155 

VI.     Cardiac  insufficiency  and  asystolism 159 

CHAPTER  VII 

Affections  of  the  Pericardium 

A.  Pericardial  effusions 161 

B.  Cardiac  symphysis  and  partial  adhesions  of  the  peri- 

cardium     165 

I.     General  data  from  radiological  examination  .      .      .  166 

a.  Pulmonary  field 166 

b.  Pleural  shadows     .  167 

c.  Mediastinal  shadows     ........  167 

d.  Heart  volume   ...    - 168 


xvi  CONTENTS 

PAGE 

II.     Data  relative  to  existence  of  pericardial  adhesions     .  169 

a.  Shadows  on  the  heart  outline  due  to  adhesions  169 

b.  Modifications  of  displacements  of  the  shadow 

of  heart  and  diaphragm 171 

1.  Apex  of  the  heart 172 

2.  Displacements  of  heart  outlines  .      .      .  174 

3.  Movements  of  the  diaphragm      .      .      .  176 

4.  Outline  of  the  heart 180 

c.  Respiratory  outline 181 

III.  Particular  data  relative  to  the  site  of  adhesions  .      .  183 

1.  Adhesions  of  base  of  heart 183 

2.  Adhesions  of  apex 183 

3.  Adhesions  in  diaphragmatic  region  ....  184 

4.  Adhesions  to  anterior  thoracic  wall  ....  184 

5.  Posterior  mediastinitis 185 

6.  Complicated  cases  .            185 

IV.  Comparison  of  the  results  of  percussion  and  ortho- 

diagraphy        185 

V.     Clinical  examples 186 

CHAPTER  VIII 

Aortitis 

I.     Normal  aorta 192 

1.  Frontal  position 192 

2.  Oblique  position 195 

3.  Nature  of  information  obtained 197 

A.  Volumetric  analysis   (three  dimensions 

method)          197 

B.  Qualitative  analysis 201 

II.     Pathological  aorta 204 

A.  Case  in  which  diagnosis  of  aortitis  is  evident 

after  objective  examination 204 

B.  Cases  in  which  subjective  symptoms  of  aortitis 

are  not  accompanied  by  any  objective  sign  .  210 

CHAPTER  IX 

Aneurisms  of  Thoracic  Aorta 

I.     General  aspect  of  aneurismal  shadows       ....  217 

II.     Analysis  of  some  radiological  signs 226 


CONTENTS  xvii 

PAGE 

III.     Diagnosis 229 

A.  Differential  diagnosis  of  aortic  aneurism  from 

other  thoracic  or  intra-thoracic  affections     .  231 

B.  Differential  diagnosis  of  aneurism  of  the  aorta 

from  dilatations  of  other  vascular  organs     .  233 

C.  Association  of  aneurism  with  other  lesions       .  233 

CHAPTER  X 

Localization  of  War  Projectiles  in  Heart  and  Pericardium 

Statistics 235 

I.     Locating  the  projectile 237 

II.     Methods  of  localization 239 

III.  Anatomical  localization 240 

IV.  Extraction  of  projectiles  under  fluoroscopic 

guidance 248 

Bibliography  relating  to  localization  of  projectiles  .      .      .  250 

Index 253 


CHAPTER  I 

RADIOLOGICAL  METHODS 

WHEN  one  examines  on  a  fluorescent  screen  a 
patient's  thorax,  one  is  struck  by  the  clearness  of 
the  cardiac  shadow.  This  results  from  the  density  of  the 
heart  which  is  relatively  opaque  to  the  x-rays,  whereas 
the  lungs  are  freely  permeable.  So  from  the  very  first, 
the  idea  arose  of  using  radioscopy  and  radiography  to 
study  the  heart,  in  the  normal  and  pathological  state.  At 
first  the  results  were  of  rather  slight  importance.  Though 
it  appeared  relatively  easy  to  estimate  the  modifications 
in  the  volume  of  the  heart,  provided  they  were  already 
sufficiently  marked,  and  to  recognize  the  existence  of 
voluminous  aneurismal  sacs,  one  did  not  feel  justified  in 
expecting  radiology  to  give  greater  precision.  Radiol- 
ogy was  believed  to  be  radically  incapable  of  furnishing 
an  exact  measurement  of  the  cardiac  diameters,  and  of 
the  changes  which  they  may  undergo  during  the  course 
of  the  same  affection.  Difficulties  which  at  first  were  not 
taken  into  account  constantly  occurred,  arising  primarily 
from  the  inadequacy  of  the  methods  of  exploration  and 
from  the  perpetually  changing  conditions  of  the  heart. 
As  the  heart  is  continually  in  motion  within  a  cavity,  of 
which  the  limits  themselves  vary  with  the  act  of  respira- 
tion, the  result  is  that  the  roentgenological  images  pre- 
sent extremely  diverse  forms.  It  was  important,  then, 
before  going  further,  to  determine  exactly  the  value  and 
the  significance  of  these  variations ;  but  that  was  realized 
only  gradually  and  in  the  course  of  the  last  few  years. 

The  first  necessity  was  to  modify  the  technic  hitherto 
employed. 


2        THE  HEART  AND  THE  AORTA 

Roentgen  rays  arising  from  a  luminous  source  consti- 
tute a  beam,  the  radiations  of  which  follow  a  divergent  or 
conical  direction,  and  from  that  there  results  an  evident 
deformation  in  the  contour  of  projected  images.  It  was 
necessary  to  attack  the  problem  of  correcting  the  causes 
of  error  due  to  this  deformation  of  shadows  and  it  will 
be  shown  that  the  problem  has  been  successfully  solved. 

There  remain  almost  no  great  difficulties  in  the  radio- 
logical examination  of  the  heart  and  the  blood-vessels. 
The  technic  has  been  so  far  perfected  that  the  images 
obtained  have  a  great  degree  of  accuracy;  the  interpre- 
tation of  them,  though  it  may  still  be  open  to  some  dis- 
pute, is  at  least  settled  definitely  in  its  broad  outlines. 

Since  the  question  of  technic  plays  such  an  important 
part  here,  it  is  fitting  to  present  a  detailed  and  critical 
study.  We  do  not  intend  to  describe  the  apparatus  neces- 
sary for  the  production  of  x-rays,  as  we  assume  it  is  well 
known,  but  we  shall  try  to  describe  carefully  the  different 
radiological  methods  used  in  the  study  of  the  heart  and 
the  blood-vessels,  to  compare  them  with  each  other,  and 
to  indicate  their  respective  advantages  and  faults. 

I.     RADIOGRAPHIC  METHODS 

1.  Time  Radiography.  This  method  consists  in  charg- 
ing a  Roentgen  tube  of  ordinary  type  with  a  low  current 
of  from  0.5  to  1  milliampere.  The  patient  is  placed  on  his 
back,  the  radiographic  plate  under  him ;  the  tube  is  placed 
over  the  sternum,  at  a  distance  of  50  to  70  centimeters. 
The  negatives  obtained  by  this  method  require  a  pro- 
longed exposure,  which  results  in  the  contours  of  the 
cardiac  shadow  becoming  blurred,  owing  to  the  pulsation 
of  the  heart  and  the  respiratory  displacements  of  the 
heart,  which  are  multiplied  during  the  exposure.  Be- 
sides, the  projection  is  enlarged  and  deformed  to  such 
an  extent  that  it  is  impossible  to  correct  it.  So  images 
obtained  by  time  radiography  are  records  of  no  value. 
This  method,  then,  should  be  rejected. 


RADIOLOGICAL  METHODS  3 

2.  Instantaneous  Radiography.  Of  late  years,  physi- 
cists and  manufacturers  have  tried,  at  the  request  of 
radiologists,  to  construct  apparatus  and  tubes  capable  of 
furnishing  a  secondary  current  of  several  milliamperes. 
This  method,  called  intensive,  allows  of  the  passage  into 
the  Roentgen  tube  of  10,  20,  60  milliamperes  and  even 
more,  during  a  very  short  space  of -time,  which  can  be 
measured  in  seconds  and  fractions  of  seconds.  The  quan- 
tity of  rays  produced  in  this  way  is  enough  to  impress 
instantaneously  supersensitive  radiographic  plates.  The 
adjustment  can  always  be  made  more  sensitive  by  the 
addition  of  an  intensifying  screen.  This  method  consti- 
tutes an  important  step  forward.  It  puts  at  the  disposal 
of  the  operator  a  large  amount  of  Roentgen  rays,  and  the 
negatives  are  obtained  with  very  short  exposures.  Thus 
it  is  easy  to  radiograph  the  thorax  of  a  patient  while  in 
the  state  of  suspended  respiration.  By  this  the  respira- 
tory displacements  are  eliminated,  and  the  negatives  gain 
much  in  clearness.  A  series  of  images  taken  during  suc- 
cessive phases  of  respiration  contribute  to  the  study  of 
the  relations  of  the  heart  and  the  diaphragm  during 
inspiration  and  expiration,  which  is  very  useful. 

In  spite  of  these  advantages,  the  image  obtained  is  de- 
formed as  in  the  preceding  method,  and  if  the  contours 
are  clearer,  the  estimate  of  the  dimensions  of  the  cardiac 
area  is  still  only  approximate. 

3.  Teleradiography.  To  avoid  the  deformations  due 
to  the  conic  projection  of  x-rays,  Kohler  (Wiesbaden) 
conceived  the  idea  of  enabling  us  to  radiograph  the  heart 
from  a  great  distance,  by  causing  the  rays  which  arise 
from  the  target  of  the  tube  to  take  a  perceptibly  parallel 
direction.  To  do  this  all  that  is  necessary  is  to  place  the 
tube  two  meters  from  the  subject,  "the  rays  which  form 
the  tangents  with  the  line  of  the  circumference  of  the 
heart  grazing  it  at  almost  equal  angles. ' '  The  parallel- 
ism of  the  rays  is  not  absolute,  but  the  errors  of  projec- 
tion are  insignificant. 


4        THE  HEART  AND  THE  AORTA 

The  source  of  the  rays  used  in  such  a  case  must  be  very 
powerful.  Several  types  of  apparatus  of  French  and 
American  make  are  capable  of  furnishing  the  necessary 
energy.  The  choice  of  a  powerful  and  resistant  tube  con- 
stitutes an  important  problem.  The  intensive  Pilon  and 
Coolidge  tubes,  not  to  mention  others,  are  excellent. 

To  obtain  a  radiogram  of  the  heart  at  a  distance,  the 
process  is  as  follows :  the  patient  is  placed  standing  or 
sitting  with  his  back  to  the  tube,  the  tube  being  2.5  to  3 
meters  away  from  him  (the  distance  of  1.5  to  2  meters, 
recommended  by  certain  operators  is  insufficient  and 
causes  deformations) ;  a  fluoroscopic  examination  is  then 
made  to  determine  the  exact  position.  When  this  is  done, 
a  radiographic  plate  is  substituted  for  the  screen  and  a 
negative  made,  the  anterior  surface  of  the  thorax  being 
in  contact  with  the  plate. 

To  radiograph  the  heart  and  the  aorta  in  oblique  posi- 
tions, the  same  procedure  is  followed,  only  the  patient 
turns  so  that  he  forms  with  the  plane  of  the  plate  an 
oblique  angle  (50  degrees  on  the  average).  The  rays 
traverse  the  thorax  obliquely  from  right  to  left  or  from 
left  to  right,  from  front  to  back  or  from  back  to  front, 
according  to  the  requirements  of  the  examination. 

The  teleradiograms  give  the  corrected  shadow  of  the 
heart  with  all  its  curves  and  all  its  angles,  constituting, 
therefore,  a  real  projection  of  the  organ.  They  show, 
moreover,  the  relations  of  the  heart  with  the  skeletal 
shadows,  with  the  lungs  and  the  diaphragmatic  arches, 
and  also  afford  valuable  records  for  the  clinician,  who 
then  can  measure  the  total  area  of  the  heart,  its  diameters 
and  outlines,  judge  the  position  of  its  contours  as  well  as 
the  form  of  the  silhouette  obtained. 

II.     RADIOSCOPIC  METHODS 

1.  Normal  Radioscopy.  This  method  gives  a  good 
general  view  of  the  thorax  and  nothing  more.  When  the 
patient  is  placed  behind  the  screen  of  platino-cyanide  of 


RADIOLOGICAL  METHODS  5 

barium  and  the  Roentgen  tube  is  charged,  we  see  the 
shadows  of  the  mediastinum  outlined  on  the  clear  borders 
of  the  lungs.  The  heart  pulsations  are  clearly  perceived, 
the  respiratory  movements  are  interpreted  by  the  verti- 
cal displacements  of  the  heart,  by  the  raising  of  the  ribs 
and  of  the  outline  of  the  thoracic  cavity,  and  by  the  lower- 
ing and  raising  of  the  diaphragm.  By  rotating  the  body 
of  the  patient  from  right  to  left  or  from  left  to  right,  the 
anterior  and  posterior  mediastinal  spaces  are  shown; 
these  appear  clear  because  of  the  slight  density  of  the 
tissues,  and  it  is  easy  to  observe  the  outline  of  the  denser 
organs,  as  well  as  to  discover  the  additional  shadows  of 
pathological  origin.  Finally,  examinations  in  the  dorsal 
or  lateral  position  complete  in  a  very  short  time  a  series 
of  observations  of  the  thoracic  shadows  as  a  whole. 

This  method,  then,  gives  general  information  about  the 
regions  x-rayed,  about  the  relations  and  the  forms  of  the 
shadows,  but  it  does  not  furnish  any  precise  information 
about  the  real  dimensions  of  the  organs;  nothing  more, 
indeed,  than  the  amplitude  of  the  movements  which 
animate  them. 

2.  Orthodiascopy.  To  correct  the  deformations  of 
Roentgen  projections,  radiologists  have  from  the  begin- 
ning suggested  an  arrangement  by  which,  by  moving  the 
tube  to  a  convenient  distance,  the  organ  under  examina- 
tion should  be  made  visible  only  at  a  point  where  the 
central  beam  of  rays,  emanating  from  the  focus,  traverses 
it  perpendicularly  to  the  plane  of  the  screen.  In  this  way, 
the  normal  ray  being  tangent  at  a  determined  point,  the 
projection  of  this  point  is  real  and  deformation  no  longer 
exists.  If,  for  example,  the  normal  ray  is  directed  at  a 
tangent  to  the  apex  of  the  heart,  the  shadow  of  the  apex 
corresponds  to  its  exact  position  in  relation  to  the  screen 
and  to  the  body  of  the  patient.  In  executing  the  same 
movement  to  determine  the  location  of  the  right  cardio- 
vascular angle,  at  the  base  of  the  heart,  a  new  point  of 
the  organ  is  marked,  and  if  the  experiment  is  repeated 


6 


THE  HEART  AND  THE  AORTA 


with  all  points  which  lie  on  the  contour  of  the  cardiac 
shadow,  the  result  is  an  accurate  projection  of  the  heart 
on  the  radioscopic  screen. 

The  diagram  in  Fig.  1  shows  the  differences  of  pro- 
jection obtained  when  the  tube  remains  at  a  fixed  point 
or  when  it  is  moved  according  to  the  orthodiascopic 
method. 


Fig.  1.    DIAGEAMS  OF  EOENTGBN  PEOJECTION 

Above,  conic  projection:  F,  focus;  F  m,  normal  ray;  ghij,  object; 
g'h'i'  j',  projection  of  the  object;  E,  E',  screen.  Below,  orthogonal  projec- 
tion: A,  A1;  A2,  etc.,  foci  occupying  different  positions,  so  that  the  normal 
ray,  A  b,  Aj  c,  A3  e,  A4  d,  is  successively  tangent  to  the  angles  of  the  object, 
b  c  d  e.    In  b'  &  d'  e',  projection  obtained  by  this  method. 

If  the  tube  is  immovable  at  F,  the  normal  ray,  F  m,  is 
directed  toward  the  center  of  the  object,  the  beam  of  rays 
emanating  from  the  focus  traverses  divergently  the  ob- 
ject, ghij,  and  projects  its  image  on  the  screen  at  g  h'  %  j'. 


RADIOLOGICAL  METHODS  7 

The  contour  of  the  shadow  obtained  is  much  greater  than 
the  contour  of  the  body  exposed  to  the  rays.  It  will  be 
noticed  that  the  normal  ray  follows  a  direction  perpen- 
dicular to  the  plane  of  the  screen ;  in  m  and  in  m,  it  is  in 
the  geometrical  center  of  the  object  and  of  its  shadow. 
The  projection  of  m  is  therefore  normal ;  but  around  this 
point  the  rays  diverge  more  and  more;  the  image  is  en- 
larged in  proportion  as  the  region  under  consideration  is 
distant  from  the  center,  m.  The  figure,  g  h'  i  j' ,  conse- 
quently, does  not  represent  a  proportionate  enlargement 
of  the  opaque  body,  but  a  deformed  image  of  it. 

If  the  x-ray  tube  is  movable  and  can  be  shifted  on  a 
plane  parallel  to  the  plane  of  the  screen,  there  is  nothing 
to  prevent  its  being  brought  to  position  A,  so  that  the 
normal  ray  shall  be  tangent  to  one  of  the  angles  of  the 
object,  b  c  d  e,  and  shall  follow,  for  example,  the  direction 
A  b.  This  ray,  or  at  least  those  immediately  contiguous, 
passing  the  opaque  body,  will  strike  the  fluorescent  screen 
perpendicularly  in  the  neighborhood  of  point  b' ,  this  point 
being  the  shadow  of  the  angle  b.  It  is  easy  to  mark  this 
point  b'  with  an  oil  crayon  on  the  glass  of  the  screen.  By 
shifting  the  tube  successively  to  Ai,  A3,  A4,  the  angles, 
c  d'  e ,  of  the  shadow  are  determined,  which  correspond 
to  the  angles  c  d  g  of  the  object.  It  is  evident  that  if  these 
points  of  the  shadow  are  connected  by  straight  lines,  a 
figure  is  obtained,  the  dimensions  of  which  are  exactly 
the  same  as  those  of  the  object. 

If,  then,  in  a  radioscopic  equipment  we  possess  means 
of  moving  the  tube  horizontally  and  vertically  on  the 
same  plane,  and  if,  moreover,  we  have  an  especial  adjust- 
ment (formed  by  crossed  wires  over  the  diaphragm  in  the 
center  of  which  passes  the  normal  ray)  by  which  we  can 
know  the  point  where  the  normal  ray  strikes  the  screen, 
it  is  possible  to  determine  the  different  regions  of  the 
cardiac  shadow  to  which  the  normal  ray  is  tangent. 

3.  Orthodiagraphy.  The  method  which  consists  in 
outlining  the  contour  of  the  shadows  according  to  their 


8        THE  HEART  AND  THE  AORTA 

normal  projection  is  the  orthodiagraphic  method.  The 
orthodiagrams  are  constructed  on  the  principle  which  we 
have  just  studied :  continual  estimation  of  the  normal  ray 
and  of  its  point  of  projection  on  the  screen,  perfect 
mobility  of  the  tube  allowing  the  passage  of  the  normal 
ray  over  the  entire  surface  of  the  screen. 

Orthodiagrams  are  of  different  models.  They  are  all 
open  to  criticism ;  the  best  is  that  which  each  individual  is 
accustomed  to  use.  It  is  not  enough  to  have  an  ortho- 
diagraph^ apparatus ;  it  is  necessary  to  have  acquired  a 
certain  dexterity.  Some  preparatory  training  is  neces- 
sary to  avail  oneself  of  all  the  advantages  which  this 
method  offers.  Physicians  who,  in  our  opinion,  depend 
too  much  on  the  mechanical  means  of  investigation,  con- 
demn orthodiagraphy  because  of  the  effort  which  it  re- 
quires of  the  clinician,  aside  from  the  study  necessary 
to  interpret  the  outlines.  The  early  difficulties  of  the 
method  are  soon  overcome  and  give  results  which  prove 
the  accuracy  of  the  investigator's  observations. 

The  first  orthodiagraphic  apparatus  was  constructed 
in  Germany.  Moritz  was  the  first  to  show  the  importance 
of  the  records  which  orthodiagraphy  gave  relative  to  the 
pathological  modifications  of  the  volume  of  the  heart. 
The  principles  of  the  method  were  applied  with  the  same 
success  by  Levi-Dorn,  Grtinmach,  Groedel,  etc.,  who  con- 
structed apparatus  which  differs  in  manipulation  and  the 
methods  of  recording,  but  which  answers  the  same  gen- 
eral purpose. 

It  is  not  necessary  to  study  these  types  of  apparatus ; 
a  description  only  of  the  orthodiagraphic  apparatus  of 
Destot  which  is  used  in  France  will  be  given. 

This  apparatus  consists  of  a  movable  holder,  one  of 
the  arms  of  which  carries  the  tube  with  its  diaphragm, 
the  other  the  small  recording  screen,  or,  in  the  more  re- 
cent models,  the  recording  crayon.  This  holder  is 
mounted  on  a  double  joint  counterpoised  and  so  regulated 
that  the  whole  system  is  in  equilibrium. 


RADIOLOGICAL  METHODS  9 

Behind  the  screen  and  parallel  to  it  is  fixed  a  frame  of 
wood;  on  that  is  placed  a  block  of  pai^er  on  which  the 
tracing  is  made.  A  crayon,  held  in  the  center  of  the 
screen,  is  jointed  in  such  a  way  that  it  can  be  lowered  to 
touch  the  sheet  of  paper,  through  a  little  opening  ar- 
ranged in  the  middle  of  the  screen.  The  adjustment  of 
the  apparatus  is  made  in  such  a  way  that  the  point  of 
the  crayon  is  always  in  the  prolongation  of  the  normal 
ray,  perpendicular  to  the  plane  of  the  screen  and  of  the 
block  of  paper.  When  the  small  recording  screen  is  not 
there,  the  crayon  remains  at  the  extremity  of  the  holder 
which  faces  the  tube,  while  the  frame  which  holds  the 
paper  is  replaced  by  a  large  screen,  and  the  tracing  is 
then  made  on  the  glass  or  on  a  small  sheet  of  celluloid 
paper  fixed  on  the  screen. 

To  take  an  orthodiagram,  the  procedure  is  as  follows : 
the  patient  is  placed  standing,  behind  the  fixed  frame,  in 
the  position  desired  (frontal,  for  example,  that  is,  the 
anterior  surface  of  the  thorax  against  the  frame),  and 
held  in  place  by  means  of  crossed  straps.  The  current  is 
turned  on  to  the  tube,  and  the  thoracic  image  appears  on 
the  screen.  As  the  crayon  is  moved,  the  tube  is  moved 
equally,  for  the  two  systems  are  coordinated;  so  that 
when  the  point  of  the  crayon  follows  the  contour  of  the 
shadow  of  the  heart,  the  heart  is  made  visible  by  a  beam 
of  x-rays,  of  which  the  normal  ray  is  tangent  to  the  out- 
line of  the  organ.  By  drawing  the  whole  length  of  the 
shadow  outline,  the  contour  of  the  exact  projection  of 
the  organ  is  traced.  Orthodiagrams  thus  obtained  are 
quite  sufficiently  precise  when  all  the  conditions  of  the 
experiment  are  minutely  observed.  Errors  of  technic  are 
insignificant ;  they  vary  from  one  to  four  and  sometimes 
five  millimeters. 

The  orthodiagraphic  apparatus  of  Destot  can  be  placed 
in  all  inclinations  between  the  vertical  and  the  horizontal 
and  so  permits  the  examination  of  patients,  as  may  be 
required,  standing,  sitting  or  lying.    Moreover,  the  trac- 


10       THE  HEART  AND  THE  AORTA 

ing  of  the  outline  can  be  made  directly  on  the  thorax  of 
the  subject. 

In  order,  however,  to  practice  orthodiagraphy  it  is  not 
necessary  to  possess  a  special  apparatus.  Some  of  the 
apparatus  of  normal  radioscopy  can  be  used  for  ortho- 
diagraphy. It  is  enough  to  realize  these  essential  condi- 
tions :  lateral  and  vertical  movability  of  the  tube  in  the 
same  plane;  absolute  immovability  of  the  screen  in  a 
plane  perpendicular  to  the  normal  ray.  But  it  is  neces- 
sary that  the  operator  be  able  easily  to  move,  with  his 
left  hand,  the  control  of  the  tube  and  of  the  diaphragm, 
in  order  that  the  right  hand  may  be  free  to  make  the 
tracing;  it  is  advisable,  besides,  that  the  screen  should 
slide  vertically  in  a  rigid  support  and  should  be  fixed  at 
variable  heights. 

We  have  given  up  the  use  of  a  screen  rigidly  connected 
with  the  tube  and  no  longer  trace  blindly  on  a  block  of  pa- 
per. We  work  on  the  lead  glass  of  a  large  screen.  The  es- 
timating of  the  normal  ray  is  done  by  means  of  the  dia- 
phragm-iris. By  reducing  the  rays  to  a  small  circular 
field  we  know  that  the  normal  ray  is  situated  in  the  cen- 
ter of  the  luminous  zone.  To  that  point  we  bring  the  part 
of  the  outline  which  interests  us  and  we  mark  on  the 
glass,  at  the  level  of  the  shadow,  a  line  with  a  broad 
crayon.  By  increasing  and  diminishing  alternately  the 
luminous  field,  the  observer  recognizes  clearly  the  area 
which  he  is  studying  and  its  relation  to  neighboring  re- 
gions. Moreover,  the  results  can  be  easily  verified,  and 
by  successive  trials  it  can  be  proved  whether  the  crayon 
marks  and  the  cardiac  outline  coincide  exactly;  also  the 
slightest  displacement  of  the  patient  can  be  noticed  and 
errors  corrected.  Correction  is  so  easy  and  so  rapid 
that  it  becomes  useless  to  strap  the  patient,  and  this 
shortens  the  operation  and  allows  a  quick  shifting  to  the 
different  positions  for  examination.  When  the  operation 
is  completed,  to  transfer  the  tracing  to  transparent  paper 
takes  but  a  moment. 


RADIOLOGICAL  METHODS  11 

4.  Teleradioscopy.  Radioscopy  from  a  distance,  or 
teleradioscopy,  offers  the  advantage  of  throwing  on  a 
screen  the  shadows  of  the  thoracic  organs  with  their  real 
dimensions. 

The  technic  is  extremely  simple.  All  that  is  necessary 
is  to  place  the  patient  before  the  screen  in  all  the  posi- 
tions necessary  for  examination.  The  radiologist  has 
only  to  trace  on  the  lead  glass  the  contour  of  the  cardiac 
shadow  without  going  through  any  process  of  correction. 

III.     PERSONAL  TECHNIC 

/ 

This  is  the  technic  which  we  employ  at  I'hopital  Saint- 
Antoine. 

We  use  a  powerful  installation  with  a  direct  current  of 
110  volts,  and  a  coil  of  50  centimeters.  With  this  appa- 
ratus we  can  practice  orthodiagraphy,  teleradioscopy  and 
teleradiography.  A  special  device  facilitates  the  succes- 
sive examinations  to  which  the  patients  are  subjected. 

These  examinations  are  as  follows:  we  begin  with 
fluoroscoping  the  thorax  as  a  whole ;  then,  by  moving  the 
tube,  we  explore  the  different  parts  of  the  cardiac  or  aortic 
shadow  which  interest  us;  we  study  the  pulsations  and 
the  respiratory  play  of  the  shadows.  After  this  prelimi- 
nary examination,  we  take  one  or  several  orthodiagraphic 
tracings  in  the  most  favorable  positions. 

When  it  seems  to  us  opportune  to  make  an  x-ray  plate 
of  the  most  characteristic  image,  we  place  the  patient 
away  from  the  tube  at  a  distance  of  at  least  two  and  a 
half  meters.  The  distance  of  one  meter,  a  meter  and  a 
half  or  even  two  meters  gives  too  considerable  deforma- 
tions. It  is  only  at  two  meters  and  a  half  that  the 
enlargement  is  reduced  to  its  practical  minimum ;  the  pro- 
jection of  an  object  fifteen  centimeters  in  size  is  aug- 
mented by  only  four  or  five  millimeters,  figures  which 
correspond  to  the  errors  of  technic  accepted  in  ortho- 
diagraphy.    It  is  necessary  that  the  tube  be  properly 


12       THE  HEART  AND  THE  AORTA 

centered  on  the  region  to  be  studied.  When  it  is  a  ques- 
tion of  the  heart,  for  example,  this  is  the  procedure:  we 
illuminate  the,  radioscopic  screen  and  by  means  of  a 
diaphragm  with  a  circular  opening  we  so  adjust  it  that 
the  image  of  the  heart  is  exactly  contained  in  the  interior 
of  the  luminous  circle,  the  diameter  of  which  should 
correspond  exactly  to  the  greatest  diameter  of  the  heart. 
We  then  fix  the  patient  and  the  tube  in  their  respective 
positions ;  we  give  the  diaphragm  a  greater  opening,  we 
place  a  plate  instead  of  the  screen  or  between  the  screen 
and  the  thorax  and  set  the  apparatus  in  action. 

As  to  teleradioscopy,  we  make  less  and  less  use  of  it. 

It  gives  precise  evaluations  when  the  patient  is  in  a 
direct  position,  especially  the  direct  anterior,  in  which  the 
thorax  is  maintained  in  contact  with  the  screen.  It  is  not 
at  all  the  same  in  oblique  positions ;  the  distance  of  cer- 
tain parts  of  the  organs  examined  amplifies  the  shadows 
and  deforms  them  in  part.  Moreover,  since  the  teleradio- 
scopes  necessitate  a  prolonged  intensive  use  of  the  tubes, 
these  deteriorate  rapidly.  Finally,  the  control  of  the  tube 
and  the  diaphragm  is  difficult  at  a  great  distance,  with  the 
result  that  the  operator  is  but  poorly  protected  against 
the  rays  which  forcibly  overspread  the  lead  glass  of  the 
screen. 

IV.     COMPARISON  OF  METHODS 

A  certain  number  of  these  methods  are  incapable  of 
giving  precise  information ;  these  are  the  methods  which 
do  not  permit  the  exact  reproduction  of  the  dimensions 
of  the  objects  according  to  their  plane  of  projection. 
Radiography  at  short  distance  is  in  this  class ;  it  furnishes 
only  useless  stereotypes,  because  the  shadows  of  the 
organs  are  deformed,  which  too  often  lead  to  gross  errors. 
It  is  therefore  necessary  to  reject  this  method  because 
the  sometimes  contradictory  data  furnished  have  proved 
confusing  to  clinicians  and  it  is  all  the  more  important  to 
insist  on  this.    It  is  necessary  to  make  the  clinician  under- 


RADIOLOGICAL  METHODS  13 

stand  that  his  misconception  arises  from  the  defective  use 
of  investigative  methods  and  that  besides  simple  radiog- 
raphy, which  can  give  erroneous  results,  tfyere  are  other 
radiological  methods  which  are  quite  reliable. 

These  methods,  three  in  number,  are:  teleradiography, 
orthodiagraphy,  and  teleradioscopy.  The  last  two  are 
identical  in  the  information  which  they  furnish  and  are 
designated  here  by  the  term  radioscopy  of  precision. 

Teleradiography  and  radioscopy  of  precision  have  each 
its  advantages.  The  association  of  the  two  methods  is 
nearly  perfect;  but  if  one  only  is  to  be  used,  then  an 
orthodiagraph^  examination  leads  to  a  more  precise 
diagnosis  than  a  teleradiography  plate. 

The  great  advantage  of  radiography  is  to  procure  one 
or  more  radioscopic  records  of  the  heart  shadows,  blood- 
vessels, neighboring  organs  and  the  thoracic  skeleton. 
Moreover,  these  shadows  have  the  actual  proportions  of 
the  organs  which  they  represent  according  to  their  plane 
of  projection ;  finally  the  value  of  the  shadow  is  propor- 
tional to  the  density  of  the  tissues.  Taking  several  plates 
in  different  positions  multiplies  the  advantages  of  tele- 
radiography. Plates  can  thus  be  interpreted  and  dis- 
cussed by  physicians  in  the  absence  of  the  patient,  with- 
out recourse  to  successive  verifications.  All  this  consti- 
tutes the  superiority  of  teleradiography  over  simple 
radiography,  but  does  not  exclude  the  advantages  of 
radioscopic  methods. 

Orthodiagraphic  tracings,  which  for  the  sake  of  sim- 
plicity are  called  cardiograms,  give  an  exactness  as  great 
as  teleradiograms,  and  the  exact  measure  of  the  shadow 
of  the  heart.  But  the  great  advantage  of  radioscopy  of 
precision  is  to  allow  the  observation  of  pulsations  and  of 
the  displacements  of  the  heart  itself  and  their  modifica- 
tions according  to  the  varied  position  of  the  patient. 
Finally,  precise  radioscopy  alone  is  capable  of  giving 
information  on  the  following  questions,  the  full  impor- 
tance of  which  will  be  seen  in  the  course  of  this  work: 


14       THE  HEART  AND  THE  AORTA 

(1)  respiratory  displacements  of  the  heart;  (2)  move- 
ments of  expansion  of  the  diaphragm;  (3)  mobility  of  the 
apex  of  the  heart;  (4)  respiratory  outline  of  the  thorax; 
(5)  evaluation  of  the  volume  of  the  left  auricle;  (6)  pul- 
sations of  the  right  ventricle;  (7)  determination  of  the 
position  of  the  left  ventricle  at  the  base  (point  G) ; 
(8)  determination  of  the  angle  of  disappearance  of  the 
apex  in  the  right  posterior  oblique  position;  (9)  meas- 
urement of  the  ventricular  development  in  depth. 

Badioscopy  of  precision  has,  then,  one  point  of  supe- 
riority over  teleradiography,  that  is,  it  produces  the 
greatest  amount  of  information  in  the  shortest  time.  One 
may  urge  against  it  that  its  records  do  not  guarantee 
impersonal  evidence  as  offered  by  radiographic  plates. 
But  whether  one  or  the  other  of  these  methods  is  used,  no 
protection  is  afforded  from  causes  of  error  which  ought 
to  be  logically  absent  from  every  record  called  imper- 
sonal. The  part  played  by  observation  is  still  consid- 
erable. The  personal  factor  intervenes  at  every  instant 
in  the  taking  of  a  radiogram,  in  the  position  of  the  patient, 
in  the  centering  of  the  tube  and  the  placing  of  the  plate. 
These  different  operations  necessitate  an  experience  and 
an  ability  which  are  not  common  to  all.  The  proof  of  it 
is  that  the  physician,  before  interpreting  a  record,  does 
not  fail  to  inform  himself  of  the  conditions  under  which 
it  was  made. 

Moreover,  for  studies  in  cardiac  radiology,  the  ideally 
impersonal  record  would  not  do. 

An  impersonal  record  is  a  dead  record.  If  it  gives 
evidence  of  a  foreign  body,  the  existence  of  a  fracture, 
the  conformation  of  a  tumor,  it  has  not  the  power  to  inter- 
pret the  life  of  an  organ  perpetually  in  motion.  When  it 
is  a  question  of  the  heart,  its  life  is  manifested  by  the 
energy  of  its  pulsations,  the  extent  of  its  displacements, 
the  density  of  its  shadows ;  when  one  examines  an  artery, 
it  is  extremely  instructive  to  note  the  amplitude  of  its 
pulsations,  the  flexuosity  of  its  contours,  the  degree  of 


RADIOLOGICAL  METHODS  15 

transparency  or  opacity  of  its  walls.  To  know  all  that, 
requires  a  competent  observer. 

But  let  no  one  misunderstand  our  opinion.  We  do  not 
pretend  that  radioscopy  of  precision  constitutes  the  only 
process  of  examining  the  heart  and  the  aorta.  As  we 
have  already  said,  we  believe  that  radioscopy  procures 
the  greatest  amount  of  useful  information.  The  radio- 
graphic record  is  secondary,  but  it  is  evidently  incom- 
parable for  fixing  by  radiographic  proof  one  or  several 
exposures  at  intervals. 

Moreover,  whichever  of  these  processes  of  precision 
we  employ, — orthodiagraphy,  teleradioscopy,  teleradiog- 
raphy,— we  shall  none  the  less  be  in  final  possession  of 
the  contour  of  the  shadows  of  heart  and  blood-vessels, 
that  is  to  say,  of  a  cardiogram  to  be  analyzed. 

It  is,  consequently,  the  interpretation  of  radiological 
images  of  the  heart  which  will  comprise  the  substance  of 
the  following  chapters. 


CHAPTER  II 

THE    SHADOW   OF   THE    HEART    IN   ITS    NORMAL 

STATE 

I.    POSITIONS  OF  THE  PATIENT— DEFINITIONS 

THE  shadow  produced  by  the  heart  on  the  fluorescent 
screen  varies  according  to  the  position  of  the  patient. 
Therefore,  to  have  images  comparable  with  each  other, 
permitting  the  methodical  study  of  the  contours  of  the 
organ  as  well  as  its  relations  with  its  surroundings,  it  is 
indispensable  to  define,  first  of  all,  the  different  positions 
for  the  study  of  the  images  desired. 

Theoretically,  in  order  that  the  information  be  as  exact 
as  possible,  the  patient  ought  to  be  examined  in  all  the 
positions  through  complete  rotation.  But  such  a  pro- 
cedure is  superfluous.  It  is  sufficient  to  take  the  radio- 
scopic  image  at  certain  intervals  to  have  all  the  indica- 
tions required.  These  different  intervals  correspond  to 
typical  positions,  in  which  it  is  expedient  that  an  image 
should  be  taken. 

These  positions  are  first  the  direct  position,  called  ante- 
rior and  posterior,  according  to  whether  the  examination 
is  made  from  the  front  or  back,  then  all  the  intermediate 
positions,  oblique,  and  lateral,  right  or  left,  according  as 
the  patient  in  rotating  presents  to  the  fluorescent  screen 
first  the  right  shoulder,  then  the  back,  then  the  left 
shoulder. 

1.  Direct  Positions.  The  direct  positions  are  two  in 
number:  the  frontal  position  or  direct  anterior,  and  the 
dorsal  position  or  direct  posterior. 

(a)  In  the  frontal  position  or  direct  anterior,  the  pa- 


SHADOW  OF  HEART  IN  NORMAL  STATE       17 

tient  faces  the  screen  and  the  operator  (radioscopy),  or 
the  radiographic  plate  (radiography).  In  this  position 
he  turns  his  back  to  the  tube;  the  rays  penetrate  the 
posterior  surface  to  the  anterior  surface  of  the  thorax 
(dorso-ventral  direction). 

(b)  In  the  dorsal  position  or  direct  posterior,  the 
patient  turns  his  back  to  the  screen  or  the  plate,  and  the 
rays  follow  an  antero-posterior  direction  (ventro-dorsal). 

In  these  two  positions  patients  can  be  examined  stand- 
ing, seated,  or  recumbent.  The  information  obtained  is 
of  the  same  absolute  value,  on  condition,  however,  that 
the  position  of  the  body  be  well  specified,  for  the  image 
of  the  heart  is  modified  accordingly. 

In  medical  practice  the  choice  of  position  is  sometimes 
imposed  by  the  condition  of  the  patient.  Certain  cardiac 
patients  suffering  from  dyspnoea  cannot  accommodate 
themselves  to  the  prone  position,  others  cannot  keep  the 
standing  position.  Besides,  each  of  these  positions  offers 
special  advantages. 

Examination  in  the  prone  position  is  recommended  for 
two  principal  reasons:  (1)  the  subject  is  perfectly  im- 
mobile; (2)  the  orthodiagraph^  findings  are  exactly  com- 
parable to  the  findings  by  percussion  which  one  generally 
takes  in  the  same  position  (with  the  patient  in  bed). 

Examination  in  the  upright  position  is  convenient  for 
the  rapid  observation  of  the  patient  in  all  positions.  By 
making  him  rotate,  the  observer  places  the  patient  suc- 
cessively in  the  frontal,  dorsal,  lateral,  and  oblique  posi- 
tions. During  these  movements  the  progressive  changes 
of  the  shadows  are  noted  and,  what  is  not  less  important, 
the  relation  of  the  projection  of  the  heart  with  the  verte- 
bral column,  the  thoracic  walls,  the  blood-vessels,  etc. 
The  oblique  examination  is  practicable  only  in  the  stand- 
ing position.  When  in  this  same  position  one  takes  the 
frontal  outline  of  the  heart  or  a  radiogram  of  it,  it  is 
important  to  have  the  patient  completely  immovable. 
The  lateral  movements  of  the  body,  even  those  that  are 


18       THE  HEART  AND  THE  AORTA 

involuntary,  are  the  most  frequent.  They  can  generally 
be  avoided  by  holding  the  anterior  region  of  the  thorax 
against  the  screen  or,  if  need  be,  by  fixing  the  shoulders 
by  means  of  crossed  straps. 

The  seated  position  gives  information  identical  with 
that  in  the  vertical  position,  provided  that  the  patient 
rests  on  an  elevated  stool  and  that  the  trunk  is  held  up- 
right. 

2.  Oblique  Positions. 

(a)  Right  anterior  oblique.  In  this  position  the  patient 
faces  the  operator  or  the  plate;  his  right  shoulder  is 
against  the  screen  or  the  plate,  and  the  plane  of  the  body 
describes  with  the  plane  of  the  screen  or  the  plate  a  more 
or  less  wide  angle. 

(b)  Left  anterior  oblique.  The  patient  faces  the  oper- 
ator or  the  plate,  the  left  shoulder  against  the  screen  or 
the  plate. 

(c)  Right  posterior  oblique.  The  patient  turns  his 
back  to  the  operator  or  to  the  plate,  the  right  shoulder 
against  the  screen  or  the  plate. 

(d)  Left  posterior  oblique.  The  patient  turns  his  back 
to  the  operator  or  to  the  plate,  the  left  shoulder  against 
the  screen  or  the  plate. 

3.  Lateeal  Positions.  The  patient  describes  with  the 
screen  or  the  plate  an  angle  of  90  degrees,  the  right 
shoulder  against  the  screen  or  the  plate.  It  is  then  in 
right  lateral  position.  Inversely,  if  the  left  shoulder  is  in 
contact  with  the  screen  or  the  plate,  the  position  is  left 
lateral. 

II.     STUDY  OF  THE  IMAGE  OF  THE  HEART  IN  ITS  PRINCIPAL 

POSITIONS 

A.       IMAGE  OF  THE  HEART  IN  THE  FRONTAL  POSITION 

The  subject  of  study,  in  the  following  descriptions,  will 
be  the  projection  of  the  shadow  of  the  heart  obtained  by 
orthodiagraphic  tracings.     It  is  self-evident  that  these 


SHADOW  OF  HEART  IN  NORMAL  STATE       19 

observations  would  apply  equally  well  to  the  image  ob- 
tained by  long  distance  radiography,  because  the  two 
processes  furnish  identical  images,  not  deformed,  which 
is  of  primary  importance,  and  which  could  not  be  realized 
by  other  methods. 


Fig.  2.    HEAET  IN  FRONTAL  POSITION 

In  order  to  understand  the  meaning  of  orthodiagraphy 
tracings  it  is  necessary  to  know,  first  of  all,  the  anatomic 
image  of  the  heart  in  the  frontal  position.  This  is  repro- 
duced in  Fig.  2. 

It  will  be  seen  that  the  right  ventricle  occupies  the 
greater  part  of  the  diagram.  It  is  bounded  above  and  at 
#the  right  (left  in  the  figure)  by  the  auricular-ventricular 
groove  that  separates  it  from  the  right  auricle,  which 
constitutes  the  upper  two-thirds  of  the  contour  of  the 
organ. 

On  the  left  side  (the  right  of  the  figure)  the  anterior 
inter-ventricular  groove  bounds  on  the  outside  a  narrow 
band  of  the  left  ventricle  from  the  base  to  the  apex. 
The  left  outline  of  the  organ  is,  then,  in  its  whole  length 
the  left  ventricle.  At  the  base  the  aorta  and  the  pul- 
monary artery  arise,  whose  respective  directions  soon 
cross. 

In  tracing  on  a  record  the  contour  of  this  anatomical 
figure,  we  obtain  the  outline  of  Fig.  3. 

On  the  right  (left  of  the  figure),  in  the  fourth  inter- 
costal space,  the  right  ventricle;  in  the  third  space,  the 


20       THE  HEART  AND  THE  AORTA 

right  auricle ;  in  the  second  space,  the  edge  of  the  sternum 
behind  which  are  the  ascending  aorta  and  the  superior 
vena  cava. 


Fig.  3.     SCHEMATIC  EECOED  OF  THE  CONTOUES  OF  THE  HEAET 

On  the  left  (right  of  the  figure),  in  the  first  space,  the 
contour  of  the  arch  of  the  aorta ;  in  the  second  space,  that 
of  the  pulmonary  artery  below  which  is  the  left  auricle ; 
in  the  third,  fourth,  fifth  spaces  the  left  ventricle. 

In  Fig.  3  we  have  indicated  the  outline  of  the  clavicles 
(cl),  of  the  sternum  (st),  and  of  the  ribs. 

The  study  of  the  radioscopic  image  of  the  heart  in 
frontal  position,  is  as  follows. 

Contours.  If  one  follows  the  contour  of  the  median 
shadow  of  the  thorax  (Fig.  4),  one  observes  at  the  left 
of  the  figure,  starting  from  the  right  diaphragmatic  dome, 
a  curved  line,  D'D,  which  circumscribes  the  right  auricle. 
Above  point  D  the  contour  follows  straight  up  as  far  as 
the  sterno-clavicular  articulation,  thus  giving  the  outline 
of  the  sternum ;  but  in  the  case  of  many  patients,  other- 
wise normal,  the  ascending  aorta  runs  slightly  over  the 
sternum  and  the  shadow  presents  a  projecture,  not 
strongly  accentuated,  following  the  line  DA. 

If  we  pass  to  the  right  side  of  the  figure,  that  is,  to  the 
left  side  of  the  patient,  the  contours  of  the  median  shadow 
present  three  semicircular  salients  or  three  superimposed 
arcs:  the  superior  or  aortic  arc  (A' A")  due  to  the  out- 


SHADOW  OF  HEART  IN   NORMAL  STATE        21 

line  of  the  descending  portion  of  the  arch  of  the  aorta ; 
the  middle  or  pulmonary  arc  (A"G)  due  to  the  salient  of 
the  pulmonary  artery,  below  which  is  seen  another  small 
salient  which  corresponds  to  the  left  auricle;  finally  the 
inferior  arc  (GG')  made  by  the  outline  of  the  left  ven- 
tricle from  the  base  to  the  apex.  This  last  is  very  near 
the  left  dome  of  the  diaphragm. 


Fig.  4.  OETHODIAGEAM  OF  THE  HEAET  AND  THE  LAEGE 
VESSELS  IN  FEONTAL  POSITION 


Particularly  interesting  contours  for  the  study  of  the 
normal  or  the  pathological  heart  are  found  between 
letters  DD'  and  GG'. 

The  line  DD'  defines  in  the  normal  state  the  contour 
of  the  right  auricle.  However,  it  may  happen  that,  in 
certain  patients,  during  radioscopic  examination,  clear 
pulsations  are  perceptible  in  the  neighborhood  of  point 
D'.  These  are  systolic  pulsations  and  describe  a  faint 
movement  above  the  diaphragm.  They  are  due  to  the 
right  ventricle,  which  shows  itself  at  this  point.  Particu- 
lar conditions  are  necessary  in  order  that  this  phenome- 
non should  occur.  If  the  heart  presents  a  vertical  form, 
if  it  lies  on  the  median  line,  if  the  apex  is  a  little  lowered 
and  turned  in,  which  results  in  a  slight  lifting  and  a 
greater  salience  of  the  right  side  of  the  heart,  it  is  easily 


22       THE  HEART  AND  THE  AORTA 

conceivable  that  the  position  of  the  right  ventricle  may 
show  above  the  diaphragm.  But  this  is  exceptional  in 
the  normal  state.  It  is  observable,  on  the  contrary,  in 
the  course  of  several  pathological  conditions  and  in  the 
following  chapter  its  interpretation  will  be  made  clear. 

The  line  GG'  demarcates  the  whole  length  of  the  border 
of  the  left  ventricle.  It  follows  a  convex  course  outward 
in  its  upper  third,  and  then  turns  round  the  apex  at  the 
level  of  the  left  diaphragm. 

The  point  G,  from  which  the  line  GG'  starts,  is  particu- 
larly interesting  to  plot  exactly,  for  it  corresponds  to  the 
position  of  the  left  ventricle  at  the  base  of  the  heart.  In 
fact,  it  is  below  the  contour  of  the  vessels,  at  the  inter- 
section of  the  middle  arc  and  the  lower  arc.  In  order  to 
determine  it  exactly  in  practice,  it  is  necessary  to  have 
recourse  to  the  orthodiagraphic  method  which  permits  the 
study  of  the  different  movements  of  the  organ. 

Indeed,  if  the  pulsations  are  observed  which  animate 
the  whole  left  side  of  the  mediastinal  shadow,  it  is  seen 
that  at  each  systole  some  pulsations  move  outward  and 
others  inward.  The  shadow  of  the  heart  undergoes  a 
retraction  movement,  while  the  vascular  shadow  de- 
scribes at  the  same  time  a  movement  of  expansion. 
Between  these  two  centers  of  pulsation,  a  small  zone  re- 
mains motionless;  it  corresponds  to  the  left  auricular 
appendage,  which  caps  the  left  auricle,  whose  contrac- 
tions are  imperceptible.  It  is  at  the  foot  of  this  neutral 
zone,  where  the  ventricular  pulsations  cease,  that  point 
G  should  be  marked.  This  point  is  usually  opposite  point 
D,  either  at  the  same  height  or  a  little  above  it,  in  tracings 
taken  in  the  recumbent  position,  or  slightly  below  in  trac- 
ings made  in  the  vertical  position.  It  is  evident  that  if 
as  a  result  of  a  pathological  modification  of  certain  car- 
diac cavities,  this  point  is  lowered  or  raised  to  an  exag- 
gerated degree,  we  may  infer  that  the  position  of  the 
ventricle  lies  higher  or  lower.  The  line  GG',  conse- 
quently, will  be  diminished  or  increased  in  length,  and 


SHADOW  OF  HEART  IN  NORMAL  STATE       23 

this  evidence  will  furnish  an  element  in  estimating  the 
ventricular  volume.  It  will  be  seen  further  how  impor- 
tant the  determination  is  of  point  G  in  the  study  of  pure 
mitral  insufficiency. 

In  the  normal  state  the  relation  of  the  lengths  of  the 
lines  GG'  and  DD'  may  be  written  in  the  following  way : 
GG'  >  DD',  and  that  means  that  the  contour  of  the  left 
side  is  more  developed  than  its  congener.  The  excess  in 
favor  of  the  first  is  from  one  to  three  centimeters. 

Finally,  it  is  to  be  noted  that  point  G'  is  situated  lower 
than  point  D'.  This  is  because  the  heart,  resting  on  the 
diaphragm  from  the  back  forward  and  from  right  to  left, 
slightly  depresses  with  its  apex  the  muscle  on  which  it 
rests  and  which  offers  only  a  feeble  resistance  on  account 
of  the  mobility  of  the  organs  that  lie  under  it. 

The  Apex  of  the  Heart.  The  apex  of  the  heart  corre- 
sponds to  the  vicinity  of  the  left  diaphragmatic  shadow, 
sometimes  a  little  above,  sometimes  a  little  below,  when 
the  subject  is  in  a  state  of  apnoea  or  superficial  respira- 
tion. During  the  movements  of  deep  inspiration  the  apex 
is  detached  from  the  diaphragmatic  shadow  as  well  as 
the  inferior  contour  of  the  heart  (Fig.  5).  This  latter  is 
then  separated  from  the  abdominal  shadow  by  a  clear 
band  more  or  less  broad.  The  transparency  of  this  region 
is  due  to  the  thinness  of  the  pericardial  folds,  which  are 
inserted  in  the  center  of  the  diaphragm,  and  this  brings 
out  the  clearness  of  the  pulmonary  tissues  situated 
behind. 

The  apex  and  the  inferior  contour  of  the  heart  are 
sometimes  outlined  even  when  the  diaphragm  is  not  mis- 
placed downward  very  much.  When  the  gas  bubble  in 
the  stomach  is  large  enough,  the  cardiac  shadow  is 
sharply  outlined  in  this  clear  gaseous  zone. 

Measurements  of  the  Shadow.  When  the  contours  of 
the  heart  have  been  traced  by  the  orthodiagraphic  method 
or  fixed  on  a  teleradiographic  plate,,  the  evaluation  of  the 
surface  thus  obtained  gives  the  real  measure  of  the  organ 


24 


THE  HEART  AND  THE  AORTA 


according  to  its  plane  of  projection ;  this  can  be  expressed 
in  two  ways : 

(a)  by  the  measure  of  the  area  of  projection,  or 

(b)  by  the  length  of  its  principal  diameters. 

(a)  Measurement  of  the  area.  Measurement  of  the 
heart  area  is  made  either  by  means  of  the  Amsler  plani- 
meter,  or  by  means  of  a  sheet  of  paper  ruled  in  milli- 
meters on  which  one  traces  the  figure  and  counts  the 
number  of  square  millimeters  to  which  it  corresponds. 


Fig.  5.  IN  DEEP  INSPIRATION  THE  APEX  AND  THE  INFEEIOE 
CONTOUR  OF  THE  HEAET  SEPARATE  FROM  THE  DIAPHRAG- 
MATIC SHADOW 


However,  the  figure  on  which  one  works  contains  arbi- 
trary elements.  It  is  only  in  the  pathological  condition 
when  the  shadow  of  the  heart  is  very  dense  that  one  is  in 
a  position  to  mark  on  the  tracing  the  lines  DGr,  corre- 
sponding to  the  base,  and  D'Gr',  corresponding  to  the 
inferior  contour.  In  the  normal  condition  this  is  not  the 
case,  and  the  construction  lines  are  simply  interpre- 
tative. And  so  the  calculation  of  the  area  can  be  only 
approximate. 

Moritz,  however,  has  judged  it  exact  enough  to  serve 


SHADOW  OF  HEART  IN  NORMAL  STATE       25 

as  a  basis  for  a  number  of  estimates  relative  to  the  size 
of  the  cardiac  area  compared  with  the  stature  of  the 
subject.1 

These  are  the  results  at  which  he  arrived : 
Stature : 

153  to  157  cm.,  area  of  the  heart  varies  from  80cm2  to 

100cm2,  average  98em2. 
161  to  169  cm.,  area  of  the  heart  varies  from  87cm2  to 

108cm2,  average  102cm2. 
171  to  178  cm.,  area  of  the  heart  varies  from  92em2  to 

126cm2,  average  109cm2. 

Bouchard  and  Balthazard,2  examining  13  men  and  36 
women,  found  that  the  average  of  the  surface  of  the  heart 
in  men  was  89.5cm2,  with  variations  from  78cm2  to  104cm2; 
in  women  76  square  centimeters,  with  variations  from  60 
to  96  square  centimeters. 

Gruilleminot  and  Chiron3  obtained  an  average  of  79em2 
in  young  people  (medical  students)  from  25  to  30  years 
old,  with  variations  from  69cm2  to  98cm2. 

Claytor  and  Merrill,*  in  studying  the  cardiac  area  com- 
paratively with  height  and  weight,  have  shown  that  there 
is  no  regular  relation  between  the  first  two  values.  On 
the  contrary  there  is  a  very  clear  relation  between  the 
cardiac  area  and  the  weight.  These  authors  show  in  the 
study  of  37  men  that  for  an  increase  in  weight  of  60  per 
cent  the  cardiac  area  increased  39  per  cent ;  this  progres- 
sion began  to  decline  when  the  weight  was  more  than  65 
kilos ;  in  women  it  is  only  25  per  cent  for  60  per  cent  in- 
crease in  weight.  These  findings  are,  moreover,  in  accord 
with  those  previously  made  by  Dietlen  and  Groedel. 

(b)  Measurement  of  diameters.  Moritz  traces  on  the 
cardiac  shadow  the  four  following  diameters. 

iMoritz,  Munch.  Med.  Woeh.,  1912. 

2  Bouchard  et  Balthazard,  1900. 

3  Chiron,  these  de  Paris,  1905. 

4  Claytor  and  Merrill,  The  Amer.  Jour,  of  the  Med.  Sciences,  Oct.,  1909. 


26 


THE  HEART  AND  THE  AORTA 


The  longitudinal  diameter  (Langsdurchmesser)  e  f 
(Fig.  6),  extending  from  the  base  of  the  heart  to  the  apex. 

The  transverse  diameter  (Querdurchmesser)  g  h,  per- 
pendicular to  the  preceding  and  following  approximately 
the  right  auriculo-ventricular  groove. 

The  two  other  diameters,  distance  from  the  middle  to 
the  right  (median-ab stand  rechts)  a  b,  and  distance  from 
the  middle  to  the  left  (median-ab stand  links)  c  d,  are 
established  in  the  following  manner :  After  having  traced 
a  vertical  line  passing  through  the  middle  of  the  sternum 
on  the  heart  shadow  a  point  of  this  line  is  joined  hori- 
zontally to  the  most  salient  point  of  the  right  auricle 
contour.  In  this  manner  a  b  is  determined  whose  length 
indicates  the  development  of  the  right  side  of  the  heart. 
By  uniting  a  point  of  the  median  line  with  the  most  salient 
opposite  point  of  the  left  ventricular  contour,  the  diam- 
eter c  d  is  obtained,  which  indicates  the  development  of 
the  left  side  of  the  heart, 


Fig.  6.     DIAMETEES  OF  THE  HEAET  ACCOEDING  TO  MOEITZ 

e  f,  longitudinal  diameter ;  g  h,  transverse  diameter ;   a  t,  diameter  from 
the  middle  to  the  right ;  c  d,  diameter  from  the  middle  to  the  left. 


The  measure  of  these  four  diameters  has  enabled  the 
author  to  draw  up  the  following  table  according  to  the 
height  of  the  patients : 


SHADOW  OF  HEART  IN  NORMAL  STATE       27 

MEN  OF  17  TO  56  YEARS 
Orthodiagraphy  Projection  in  Horizontal  Recumbency 


Diameter 

Diameter 

from 
middle 

from 
in  iddle 

Longitu- 
dinal 

Transverse 

Height- 

to  right 

to  left 

diameter 

diameter 

m  cm. 

in  em. 

m  cm. 

in  cm. 

III   rill. 

153-157 

Average 
Maximum 

4.4 

4.8 

7.9 

8.0 

13.0 
13.5 

10.2 

10.5 

Minimum 

4.0 

7.8 

11.5 

10.0 

161-169 

Average 
Maximum 

4.4 
5.0 

8.3 
9.3 

13.4 
14.5 

10.5 
10.8 

Minimum 

3.5 

7.5 

12.8 

9.0 

Average 

4.6 

9.8 

14.0 

10.3 

171-178 

Maximum 

5.9 

15.3 

15.3 

11.3 

Minimum 

3.0 

12.5 

12.5 

9.0 

Claytor  and  Merrill  have  proceeded  otherwise.  They 
estimated  that  to  measure  two  diameters  was  sufficient; 
a  longitudinal  diameter  starting  from  the  base  of  the 
heart,  at  the  intersection  of  the  cardiac  curve  and  of  the 


Fig.   7.     DIAMETERS   OF   THE   HEART   ACCORDING   TO   CLAYTOR 

AND  MERRILL 

LD,  diameter  longitudinal ;  MR  +  ML  =  transverse  diameter. 


28 


THE  HEART  AND  THE  AORTA 


origin  of  the  blood-vessels,  and  extending  to  the  apex, 
and  a  transverse  diameter  which  represents  the  total  of 
the  two  half -diameters  (middle  to  left  and  middle  to 
right  according  to  Moritz — see  Fig.  7).  Finally  they  took 
as  the  basis  of  comparison  not  the  height  but  the  weight 
of  the  patients : 


CLAYTOE  AND  MEEEILL 

Table  I.    Orthodiagrams  of  Men  in  Vertical  Position 


Weight 
in  pounds 

Transverse 

diameter  in  cm. 

MB-\-  ML 

Longitudinal 
diameter)*  in  cm. 

109-117 

Minimum 

Average 

Maximum 

10.7 
10.9 
11.3 

11.8 
12.6 
13.5 

118-126 

Minimum 

Average 

Maximum 

11.0 
11.8 
12.5 

12.0 

13.2 
14.0 

127-135 

Minimum 

Average 

Maximum 

11.0 
11.9 
13.1 

12.0 
13.4 

14.5 

136-144 

Minimum 

Average 

Maximum 

11.5 
12.3 

13.0 

12.5 
13.5 
15.0 

145-162 

Minimum 

Average 

Maximum 

12.0 
12.4 
13.8 

14.0 
14.6 
15.3 

163-181 

Minimum 

Average 

Maximum 

11.0 
12.9 
13.4 

14.0 
14.7 
15.8              ! 

SHADOW  OF  HEART  IN  NORMAL  STATE       29 


CLAYTOR  AND  MERRILL 
Table  II.     Orthodiagrams  of  Women  in  Vertical  Position 


Weitjht 
in  pounds 

Transit  rse 

(Humclrr  in  cm. 

Longitudinal 
diameter  in  cm. 

91-99 

Minimum 

Average 

Maximum 

9.9 
10. L> 
10.5 

12.0 

12.1 
12.3 

100-108 

Minimum 

Average 

Maximum 

10.0 

10.7 
11. 1 

11.5 
11.9 

12.4 

109-117 

Minimum 

Average 

Maximum 

10.2 
11.0 
12.2 

10.5 
12.2 
13^8 

118-126 

Minimum 

Average 

Maximum 

9.6 
11.2 
12.6 

11.2 
12.4 
13.3 

127-135 

Minimum 

Average 

Maximum 

10.0 
11.1 
11.8 

12.2 
12.7 
13.2 

136-144 

Minimum 

Average 

Maximum 

10.9 
11.6 
12.8 

12.3 
12.9 
14.2 

145-159 

Minimum 

Average 

Maximum 

10.6 
11.7 
12.6 

11.8 
12.6 
13.2 

The  process  which  we  have  adopted  and  usually  em- 
ploy differs  little  from  the  preceding.  We  thought  it 
necessary  to  reject  the  method  of  Moritz,  because  it 
seemed  to  us  to  be  based  on  an  erroneous  conception. 
Moritz  established  the  measurement  of  the  heart  by  con- 
sidering it  as  a  perfect  ovoid,  the  figure  thus  obtained 
believed  to  be  geometric.  This  is  not  true  to  fact.  We 
thought  it  more  logical  to  adhere  to  the  method  of  tracing 


30 


THE  HEART  AND  THE  AORTA 


only  diameters  that  terminate  in  real  salients  in  the  con- 
tour of  the  heart.  It  is  sufficient  to  know  two  diameters 
only  in  order  to  have  an  exact  idea  of  the  volume  of  the 
organ. 

Now,  these  two  diameters  to  be  determined  are  the 
longitudinal  and  the  transverse  or  horizontal. 

The  diameter  of  the  height  or  the  longitudinal  diame- 
ter begins  from  the  intersection  of  the  right  contour  of 
the  heart  and  of  the  origin  of  the  blood-vessels  and  ends 
at  the  apex  (line  DG  of  Fig.  8). 


A3 


Fig.  8.    DIAMETERS  OF  THE  HEART  (VAQUEZ  AND  BORDET) 
d  I,  longitudinal  diameter ;  h  -\-  h',  horizontal  diameter. 

The  transverse  or  horizontal  diameter  is  determined  a 
little  differently.  It  ought  to  represent  the  greatest  dis- 
tance which  separates  the  right  border  from  the  left 
border,  but  it  is  exceptional  that  the  greatest  develop- 
ment of  each  of  the  two  sides  of  the  heart  should  corre- 
spond to  a  horizontal  line ;  most  often  it  is  a  more  or  less 
oblique  line  uniting  the  two  extreme  points.  Now  it  is 
interesting  to  have  the  horizontal  direction  of  this  line 
preserved.  We  arrive  at  this  by  bringing  two  lines  start- 
ing from  the  right  and  from  the  left  side  of  the  heart  to 
the  point  where  each  of  them  is  most  distant  from  the 


SHADOW  OF  HEART  IN  NORMAL  STATE       31 

sternum  and  ending  on  the  medio-sternal  line.  By  adding 
these  two  half-diameters,  we  have  the  horizontal  line  we 
seek. 

In  the  recumbent  position,  as  we  have  said,  the  two 
diameters,  longitudinal  and  horizontal,  are  perceptibly 
equal.  Sometimes,  however,  the  first  is  greater  than  the 
second  by  from  5  mm.  to  about  1  cm. ;  in  exceptional  cases 
it  is  less  by  several  millimeters.  In  the  standing  position, 
the  longitudinal  position  may  be  increased  a  little,  which 
is,  however,  very  rare;  on  the  contrary,  the  horizontal 
diameter  always  diminishes.  It  then  becomes  inferior  to 
the  other  by  from  5  mm.  to  1  cm. 

The  results  which  we  have  obtained  in  the  course  of 
many  measurements  are  fairly  comparable  to  those  of 
Claytor  and  Merrill.  Like  these  authors,  we  have  seen 
that  the  variations  in  the  volume  of  the  heart  were  pro- 
portionate to  the  weight  rather  than  to  the  height  of  the  it 
patient.  But  it  should  be  understood  that  the  weight  here 
expresses  the  physical  and  muscular  development  and  not 
excess  of  fatty  tissue.  It  is  interesting  to  note  that  this 
is  the  conclusion  reached  by  Polain  and  Vaquez,  from 
measurements  taken  after  percussing  the  heart  area  in 
young  patients. 

A  third  diameter  of  secondary  value  (Fig.  8a)  is  ob- 
tained by  joining  the  base  of  the  left  ventricle  (or  point 
G)  with  the  right  cardio-diaphragmatic  angle  (or  point 
D').  This  is  designated  as  diameter  D'G.  Its  length 
indicates  the  distance  which  separates  the  point  of  origin 
of  the  right  ventricular  outline  from  the  point  of  origin  of 
the  left  ventricular  outline,  in  other  words,  by  develop- 
ment in  size  of  the  base  of  the  ventricles.  Van  Zwaluwen- 
burg  and  Warren5  and  Otten6  have  drawn  attention  to  the 
practical  interest  of  this  diameter.     It  is  shown  on  the 

s  Van  Zwaluwenburg  and  Warren,  Archives  of  internal  medicine,  f  ol. 
1911. 

6  Otten,  Die  Bedeutung  des  OrthodiagrapJiies  fur  die  ErTcennung  der 
ieginnenden  Herzweiterung,  Deuts.     Arch.  f.  Kl.  Medi.,  Febr.,  1912. 


32 


THE  HEART  AND  THE  AORTA 


figure,  either  by  connecting  D'  and  Gr  by  a  straight  line  or 
by  dropping  from  D'  and  Gr  two  perpendicular  lines  to  the 
longitudinal  diameter.  In  the  latter  case,  the  sum  of  the 
two  half-diameters  thus  traced  gives  the  diameter  D'Gr. 
The  evaluation  of  this  measurement  is  sometimes  useful 
in  translating  into  figures  the  hypertrophy  of  the  ven- 
tricles at  their  base.  It  is  evident  that  if,  for  example, 
the  walls  of  the  left  ventricle  increase  in  thickness,  the 
point  G'  will  be  pushed  to  the  left,  and  consequently  the 
line  DGr'  will  be  increased  in  proportion.  The  same  fact 
arises  if,  on  the  contrary,  it  is  the  point  D'  which  is 
thrown  toward  the  right  as  a  result  of  dilatation  or  of 
hypertrophy  of  the  right  ventricle.  In  a  series  of  exami- 
nations of  the  same  patient,  this  diameter  may  be  the 
only  one  to  vary,  while  the  other  two  are  but  little  modi- 
fied, which  gives  added  means  of  studying  the  changes  in 
the  volume  of  the  heart  (see  below  the  figures  in  Chapter 
V). 


/        Dy 

/"" 

/ 

s^"'~ 

G 

^ 

Fig.  8a.    DIAMETEES  OF  THE  HEART.* 

DG',  longitudinal  diameter; 
D'G,  third  diameter; 
O,  point  of  intersection. 

*  This  figure  was  omitted  from  the  French  text  which  the  translators  used, 
a  text  printed  in  the  stress  of  war.  It  appeared  among  the  plates  received 
from  France  after  the  English  version  was  in  type.  Hence  the  irregularity 
in  the  numbering. — Tr. 


SHADOW  OF  HEART  IN  NORMAL  STATE       33 

The  point  of  intersection  of  the  diameter  D'G  and  of 
the  longitudinal  diameter  (or  point  0),  the  position  of 
which  varies  according  to  the  degree  of  inclination  of 
these  two  diameters,  has  led  Van  Zwaluwenburg  and 
Warren  to  study  the  relation  of  the  two  distances  DO  and 
OG'.  This  relation  is  approximately  proportionate  to 
the  relation  of  the  auricular  area  to  the  ventricular  area. 
The  ratio  DO :  OG'  would  represent  the  relation  of  the 
areas  of  the  auricles  and  the  ventricles.  The  figure 
obtained,  or  index,  would  vary  in  normal  subjects 
between  0.534  and  0.704.  It  would  increase  when  the  area 
of  the  auricles  increases  and  it  would  diminish  when  the 
area  of  the  ventricles  predominates.  These  authors  have 
found,  indeed,  in  mitral  stenosis  the  index  1000,  and  in  a. 
case  of  interstitial  nephritis  the  index  280. 

Mobility  of  the  heart.  To  test  the  mobility  of  the  heart, 
the  patient,  placed  behind  the  radioscopic  screen,  is  made 
to  bend  the  body  from  right  to  left  of  the  vertical  axis. 

"When  the  inclination  is  toward  the  left,  the  heart  de- 


Fig.  9.  LATEEAL  INCLINATION  OF  THE  BODY  TO  THE  LEFT 

The  black  lines  are  the  outlines  of  the  heart  in  the  vertical  position 
(drawn  on  the  skin).  The  dotted  lines  are  the  outline  in  left  lateral 
inclination. 


34 


THE  HEART  AND  THE  AORTA 


viates  from  the  median  line  by  about  one  to  two  centi- 
meters, which  is  easy  to  determine  if  one  is  careful  to 
mark  on  the  skin  of  the  patient  the  two  successive  tracings 
of  the  contour  of  the  apex  in  these  different  positions 
(Fig.  9). 

The  position  of  the  heart  varies  equally  when  the  pa- 
tient passes  from  the  vertical  position  to  the  horizontal 
recumbent  (Fig.  10).  In  the  vertical  position  the  heart 


Fig.  10. 


Black  lines,   projection   in   recumbent   position.      Dotted  lines,   standing 
position. 


pulls  on  the  insertions  of  the  base  and  on  the  blood- 
vessels, it  rests  more  on  the  diaphragmatic  dome,  and  in 
consequence  is  lowered  as  a  whole.  In  the  recumbent 
position,  the  heart  seems  to  spread,  compressed  as  it  is 
above  and  behind. 

Displacements  due  to  respiration.  During  deep  inspira- 
tion the  heart  follows  the  movements  of  the  diaphragm 
and  is  lowered.  At  the  same  time,  the  organ  changes  a 
little  in  form  and  its  diameters  vary  slightly;  the  longi- 
tudinal diameter  increases  and  the  horizontal  diameter 
diminishes ;  the  result  is  an  elongation  and  a  narrowing 
of  the  shadow  of  the  heart. 


SHADOW  OF  HEART  IN  NORMAL  STATE   35 

During  deep  expiration,  the  contrary  is  observed. 
Under  the  pressure  of  the  diaphragm,  the  heart  is  raised 
and  spreads;  both  diameters  increase,  the  horizontal 
more  than  the  longitudinal. 

Here,  for  example,  are  the  figures  noted  in  the  case  of 
a  normal  subject  thirty  years  old. 

Average  Forced  Forced 

respiration       inspiration        expiration 

Longitudinal  diam.  in  cm. 

11.5  11.8  13.5 

Horizontal  diam.  in  cm. 

11.5  11.2  15.1 

The  preceding  considerations  bear  only  on  forced 
movements  of  inspiration  and  expiration.  If  the  respira- 
tion is  quiet,  the  volume  of  the  heart,  as  Groedel7  has 
remarked,  does  not  change  notably. 

Not  less  important  are  the  modifications  which  the 
respiration  causes  in  the  relations  of  the  heart  with  the 
diaphragm : 

(a)  In  recumbency,  forced  inspiration  lowers  the  heart 
and  the  diaphragm  much  below  their  average  position  (or 
as  in  quiet  inspiration).  The  descending  movement  of 
the  diaphragm  extends  to  a  distance  of  3  to  5  centimeters. 

During  forced  expiration,  the  heart  and  the  diaphragm 
are  raised  only  very  little  above  their  average  position  in 
quiet  expiration.     (See  Fig.  11.) 

(b)  In  the  vertical  position  it  is,  on  the  contrary,  forced 
expiration  which  causes  the  most  considerable  movement 
of  the  heart  and  of  the  diaphragmatic  contour,  but  in  this 
case  it  is  the  height,  whereas  forced  inspiration  lowers  to 
only  a  moderate  degree  the  heart  and  the  diaphragm 
below  their  average  position  (Fig.  12). 

7  F.  M.  Groedel,  Mudes  radio-cinematographiques  relatives  a  I'influence 
de  la  respiration  normale  sur  la  grandeur  et  la  position  du  ceeur.  (Zeits.  f. 
Klin.  Med.  Band  LXXII,  pp.  292,  310.) 


36 


THE  HEART  AND  THE  AORTA 


When  the  patient  is  standing,  the  heart,  suspended  in 
the  pericardial  sac,  tends  to  weigh  npon  the  diaphragm 
and  drop  nnder  the  influence  of  its  own  weight;  forced 
inspiration  adds  very  little  to  this  movement.  It  is  quite 
otherwise  in  recumbency.  The  heart  is  then  placed 
higher.  But  the  insertions  of  the  base  hold  it  only  lightly, 
yielding  very  easily  to  the  tension  which  the  diaphragm 
makes  on  it  during  deep  inspiration. 


Fig.  11.     TRACINGS  MADE  IN  RECUMBENCY 

The  black  lines,  quiet  respiration.     Dotted  lines,  forced  expiration.     Dot- 
and-dash  lines,  forced  inspiration. 


Heart  pulsation.  The  radiological  study  of  the  pulsa- 
tion of  the  heart  has  not  advanced  much  yet,  not  because 
it  lacks  interest,  but  because  of  difficulties  of  a  technical 
nature.  Radioscopy  gives  only  a  glimpse  of  the  heart 
pulsations,  but  this  little  is  of  sufficient  value  in  different 
cardiopathies  to  attract  attention. 

It  will  be  necessary  in  order  to  record  the  constant 
movement  of  the  different  parts  of  the  heart  that  cine- 
mato-radiography  should  become  a  method  more  con- 
stantly used.  It  alone  will  be  able  to  record  the  heart 
changes,  that  is,  the  succession,  the  amplitude,  even  the 
form  of  the  contraction  of  the  different  parts  of  the  heart. 
We  shall  perhaps  be  able  then  to  easily  recognize  aortic 


SHADOW  OF  HEART  IN  NORMAL  STATE   37 

insufficiency  by  simply  observing  the  ample  systolic  re- 
traction of  the  ventricular  shadow;  cardiac  insufficiency 
by  the  lagging  undulation  of  the  left  side  of  the  heart; 
tachycardiac  attack  by  the  sudden  explosion  of  the  pulsa- 
tions; mitral  stricture  by  the  intensity  of  the  auricular 
contraction,  etc. 


Fig.  12.     TEACINGS  TAKEN  IN  THE  VERTICAL  POSITION 

Black  lines,  quiet  respiration.  Dotted  lines,  forced  expiration.  Dot-and- 
dash  lines,  forced  inspiration. 

A.  W.  Crane,8  starting  from  the  work  of  Gocht  and 
Rosenthal,  has  succeeded  in  making  radiographic  trac- 
ings of  the  heart  pulsation.  He  proceeds  in  the  following 
manner:  he  covers  the  precordial  region  with  a  sheet  of 
lead,  in  which  he  makes  narrow  horizontal  openings,  in 
such  a  way  that  only  certain  parts  of  the  cardiac  outline 
are  projected  on  the  sensitive  plate.  These  openings  may 
be  multiplied  over  the  ventricular,  auricular,  aortic  and 
other  contours.  A  radiographic  film  is  slipped  in  front 
of  these  openings,  with  the  rapidity  requisite,  during  ex- 
posure of  the  thorax  to  the  x-rays  from  back  to  front. 
Tracings  are  thus  obtained  comparable  to  sphygmograms 
and  electro-cardiograms.    The  strength  or  the  weakness 

8  A.  W.  Crane,  Roentgenology  of  the  Heart.  (American  Roentgen  Ray 
Society,  annual  meeting,  Sept.  6,  1916.) 


38       THE  HEART  AND  THE  AORTA 

of  the  pulsations  of  the  different  heart  cavities  is  inter- 
preted by  the  variations  in  the  amplitude  of  the  curves. 
These  readings  furnish  valuable  elements  in  diagnosis. 

B.       IMAGE  OF  THE  HEAET  IN  OBLIQUE  POSITIONS 

Right  posterior  oblique  position.  In  this  position  the 
patient  rests  his  right  shoulder  against  the  screen  with 
his  back  to  the  observer.  His  left  shoulder  is,  conse- 
quently, the  farthest  from  the  screen  and  its  distance  is 
maximum  when  the  line  which  passes  through  the  two 
shoulders  (the  bi-scapular  axis)  forms  a  right  angle 
with  the  plane  of  the  screen.  As  the  left  shoulder  ap- 
proaches the  screen,  the  angle  of  obliquity  of  the  body 
diminishes. 

When  in  the  right  oblique  posterior  position  the  pa- 
tient is  made  to  pivot  round  a  fixed  point  which  is  the 
right  shoulder,  in  such  a  way  as  to  make  the  left  shoulder 
gradually  more  distant,  the  angle  of  obliquity  of  the  body 
passes  successively  from  20  to  25,  30,  35  degrees,  etc. 
During  this  movement,  the  shadow  of  the  thoracic  organs 
is  necessarily  modified  according  to  the  incidence  of  the 
beam  of  rays.  The  shadow  of  the  vertebral  column  which 
was  in  the  middle  of  the  screen  is  displaced  toward  the 
left,  that  of  the  left  ventricle,  which  projected  markedly 
to  the  left,  is  transferred  toward  the  right.  These  two 
shadows,  traveling  in  opposite  directions,  finally  cross, 
then  the  apex  of  the  heart  approaches  the  vertebral 
column  and  finally  disappears  behind  its  shadow. 

In  calculating,  then,  the  angle  formed  by  the  bi-scapu- 
lary  axis  of  the  patient  with  the  plane  of  the  screen,  we 
have  the  angle  at  which  the  apex  disappears.  This  nota- 
tion, made  only  during  orthodiascopic  examination,  has 
unquestionable  practical  value;  for  the  angle  at  which 
the  apex  of  the  heart  disappears  in  this  position  is  an 
indication  of  the  development  of  the  organ.  To  know  the 
degree  of  it  is  added  evidence  in  estimating  the  volume 
of  the  heart.    In  normal  subjects  this  angle  is  generally 


SHADOW  OF  HEART  IN   NORMAL  STATE       39 

from  25  to  30  degrees  (Fig.  13) ;  if  it  is  40,  45,  50  degrees, 
it  can  be  concluded  that  the  ventricular  cavities  are 
increased  in  volume. 


Fig.  13.     ORTHODIAGRAM  OF  A  NORMAL  HEART  IN  THE  RIGHT 
POSTERIOR  OBLIQUE  POSITION  AT  30  DEGREES 

The  apex  of  the  heart  disappears  behind  the  shadow  of  the  vertebral 
column. 

To  determine  precisely  and  rapidly  the  degree  of  ob- 
liquity of  the  body,  Boulitte  has  constructed  an  angle 
indicator  or  goniometer  which  is  of  practical  value.  This 
apparatus  consists  of  a  horizontal  wood  rule  to  which  are 
fastened  two  perpendicular  pieces  of  wood,  the  distance 
between  which  can  be  regulated  by  a  series  of  grooves 
and  which  allows  them  to  be  fixed  at  any  point.  In  the 
posterior  position  the  patient  turns  his  back  to  the  rule 
and  the  two  perpendicular  pieces  are  placed  in  the  center 
of  the  scapular  regions.  In  the  anterior  position,  these 
two  pieces  hold  the  patient,  either  as  we  have  just  ex- 
plained, or  as  is  preferable  in  oblique  angles  of  less  than 
50  degrees,  on  the  anterior  surface  of  the  body,  at  the 
external  third  of  the  clavicle.  The  bi-scapular  axis  of 
the  body  then  remains  parallel  to  the  direction  of  the 
rule.  The  rule  pivots  on  one  end  which  is  fastened  to  the 
frame  of  the  screen,  which,  for  this  examination,  should 
have  a  fixed  position.  The  joint  end  of  the  rule  has  a 
divided  dial.  Since  the  apparatus  is  fixed  to  the  body 
all  that  is  necessary  for  determining  the  angle  of  obliq- 


40 


THE  HEART  AND  THE  AORTA 


uity  is  to  lower  the  rule  by  means  of  a  screw  and  to  read 
the  figure  indicated  on  the  dial.     (See  Fig.  14.) 


Fig.  14.    GONIOMETEE  OF  VAQUEZ  AND  BOKDET 


If  we  continue  the  movement  just  described  until  the 
patient  is  in  the  right  posterior  oblique  position,  at  an 
angle  of  50  degrees,  an  image  is  obtained  of  the  mediasti- 
nal organs  represented  by  Fig.  16.  In  order  to  under- 
stand it,  it  is  necessary  in  the  first  place  to  know  to  what 
part  of  the  organ  the  outline  of  the  shadow  corresponds. 
An  examination  of  the  subjoined  diagram  (Fig.  15)  will 
show  it. 

It  is  evident  that  the  normal  ray  n  n'  enters  the  left  wall 
of  the  thorax  and  comes  out  at  the  right  wall ;  tangent  to 


SHADOW  OF  HEART  IN  NORMAL  STATE       41 

the  heart  on  the  side  of  the  vertebral  column,  it  reaches 
the  left  auricle,  the  walls  of  which  form  the  most  salient 
part  of  the  heart  on  a  level  with  the  eighth  cervical  verte- 
bra. By  picturing  the  anatomical  aspect  in  elevation,  we 
deduce  that  it  is  the  ventricular  surface  only  which  ought 
to  develop  below  the  auricle  and  if  the  ray  passes  a  little 
lower  it  is  then  the  shadow  of  the  left  ventricle  which  is 
projected  on  the  screen. 


Fig.   15.     DIAGEAMMATIC  ANATOMICAL  CEOSS-SECTION   (AFTEE 
LUSCHKA).    EIGHT  POSTEEIOE  OBLIQUE  POSITION 

T,  Boentgen  tube;  n  n',  course  of  the  normal  ray;  E  E,  screen;  VG,  left 
ventricle;  VD,  right  ventricle;  OG,  left  auricle;  OD,  right  auricle. 

By  turning  to  the  orthodiagraphic  tracing  (Fig.  16, 
from  left  to  right)  and  studying  the  details,  the  following 
is  found: 

P  G,  a  clear  zone,  the  left  lung ;  c,  the  shadow  of  the 
vertebral  column;  e,  the  retro-cardiac  clear  space;  OG 
(below  the  outline  of  the  aorta),  the  contour  of  the  left 


42 


THE  HEART  AND  THE  AORTA 


auricle,  above  the  outline  of  the  left  ventricle,  VG;  VD, 
the  outline  of  the  right  ventricle;  finally,  PD,  the  clear 
field  of  the  right  lung. 

The  most  interesting  part  of  this  figure  is  the  left 
auricle,  OGr.  This  is  outlined  sharply  in  the  position 
which  is  very  favorable  for  the  examination  of  this  cav- 
ity, which  occupies  here  the  postero-superior  two-thirds 
of  the  cardiac  shadow. 


Fig.  16 


Fig.  17 


Fig.  16.    OETHODIAGEAM  TAKEN  IN  EIGHT  POSTEEIOE  OBLIQUE 
POSITION  AT  50  DEGEEES 

Fig.  17.  PEOJECTION  IN  EIGHT  POSTEEIOE  OBLIQUE  POSITION 
OF  A  SOUND  AND  OF  A  TUBE  IN  THE  CESOPHAGUS;  THE 
TUBE  EESTS  ON  THE  LEVEL  WITH  THE  EIGHT  AUEICLE 


To  make  sure  of  it,  we  objectified  the  auricle  pulsations 
by  means  of  a  tube  introduced  into  the  oesophagus  and 
connected  with  a  recording  stylus.  The  tube  was  filled 
with  bismuth.  Now,  the  patient  being  in  front  of  the 
screen,  it  was  seen  that  the  visible  pulsations  of  the 
auricle  were  produced  just  at  the  moment  when  the  tube 
was  in  the  region  indicated  above  (Fig.  17). 


SHADOW  OF  HEART  IN  NORMAL  STATE       43 

The  distance  which  separates  the  outline  of  the  heart 
from  the  shadow  of  the  vertebral  column  diminishes  as 
the  angle  of  obliquity  diminishes ;  very  narrow  at  40  de- 
grees, it  is  much  larger  at  50  degrees.  This  latter  inci- 
dence is  the  most  favorable  for  the  study  of  the  heart 
walls  outlined  in  the  retro-cardiac  clear  space,  especially 
for  the  study  of  the  left  auricle.  However,  in  the  case  of 
patients  whose  thorax  is  underdeveloped  or  narrow,  the 
angle  of  obliquity  should  be  as  great  as  60  degrees. 

When  the  volume  of  the  left  auricle  is  increased,  the 
salience  of  its  shadow  is  accentuated  and  its  contour 
approaches  the  vertebral  column,  the  reasons  for  which 
have  just  been  indicated.  Its  development  is  known  only 
if  it  is  known  at  what  angle  the  patient  was  placed. 

Left  posterior  oblique  position.  In  this  position  at  an 
angle  of  50  degrees  the  normal  ray  penetrates  the  right 
antero-lateral  thoracic  region  and  comes  out  at  the  left 


Fig.  18.    ANATOMICAL  CKOSS-SECTION  IN  LEFT  POSTEEIOE 
OBLIQUE  POSITION 


44 


THE  HEART  AND  THE  AORTA 


posterior  thoracic  region;  at  the  oesophageal  zone  level, 
it  is  tangent  to  the  posterior  wall  of  the  two  auricles, 
especially  the  right  auricle.  The  left  auricle  and  the  left 
ventricle  are  nearest  the  observer  and  the  major  axis  of 
the  heart  nearly  parallel  to  the  plane  of  the  screen  (Fig. 
18).  The  apex  of  the  heart  on  the  left  ought  then  to  be 
seen  and  a  projection  obtained  extending  to  the  external 
wall.  This  is  exactly  what  is  shown  on  the  orthodiagram 
(Fig.  19).  On  the  other  hand,  in  this  latter  figure,  it  is 
seen  that  the  contour  of  the  heart  outlines  in  the  clear 
space  the  auricles,  notably  the  right,  and  toward  the 
diaphragm  the  lower  part  of  the  left  ventricle.  At  the 
right  of  the  figure  the  tracing  outlines  the  auricles  above, 


Fig.  19. 


ORTHODIAGRAM  TAKEN  IN  THE  LEFT  POSTERIOR 
OBLIQUE  POSITION  AT  50  DEGREES 


OD,  right  auricle;   OG,  left  auricle;  VG,  left  ventricle;   p,  apex  of  the 
heart. 


the  left  ventricle  below;  during  radioscopic  examination, 
the  pulsations  of  the  apex  at  p  are  clearly  seen. 

Right  anterior  oblique  position.  This  position  is  in  a 
way  the  inverse  of  the  preceding.  The  normal  ray  enters 
at  the  left  posterior  thoracic  wall  and  comes  out  through 


SHADOW  OF  HEART  IN  NORMAL  STATE  45 

the  right  antero-lateral  thoracic  region   (Fig.  20) ;  the 

right   auricle   and   the    right   ventricle   are   nearer  the 
observer. 


Fig.  20. 


ANATOMICAL  CROSS-SECTION  IN  THE  RIGHT  ANTERIOR 
OBLIQUE  POSITION 


In  Fig.  21,  the  left  contour,  the  outline  of  which  is  seen 
in  the  retro-cardiac  clear  space,  does  not  show,  at  50  de- 
grees at  least,  the  right  but  the  left  auricle.  The  posterior 
wall  of  this  cavity  is  found  to  be  nearest  the  dorsal  wall 
of  the  body.  If  the  bi-scapular  axis  describes  an  angle 
greater  than  50  degrees,  the  left  auricle  shows  more;  if, 
on  the  contrary,  the  angle  is  less  than  50  degrees,  it  is 
the  contour  of  the  right  auricle  which  appears. 

Below  the  auricular  shadow,  in  the  clear  space,  the 
right  ventricle  is  outlined. 

At  the  right  of  the  figure  the  contour  of  the  organ  out- 
lines the  right  auricle  above;  below  and  all  along  the 
diaphragm,  the  right  ventricle. 

Left  anterior  oblique  position.    The  normal  ray  enters 


46       THE  HEART  AND  THE  AORTA 


Fig.  21.     OETHODIAGEAM  TAKEN  IN  THE  EIGHT  ANTEEIOE 

OBLIQUE  POSITION  AT  50  DEGEEES 
OG,  left  auricle;  OD,  right  auricle;  VD,  right  ventricle. 


n,     T 


E 

Fig.  22.     ANATOMICAL  CEOSS-SECTION  IN  LEFT  ANTEEIOE 
OBLIQUE  POSITION 


SHADOW  OF  HEART  IN  NORMAL  STATE   47 

the  right  posterior  thoracic  wall  and  comes  out  at  the  left 
antero-lateral  costal  wall  (Fig.  22).  At  50  degrees  the 
orthodiagraph^  tracing  is  obtained  as  seen  in  Fig.  23. 
The  outline  of  the  heart  in  the  clear  space  shows  the  left 
auricle  in  the  upper  part  and  the  left  ventricle  in  the 
lower  part.  At  the  level  of  the  diaphragm,  the  contour 
curves  sharply  to  the  left  downward.  The  apex  of  the 
heart  lies  at  p  and  is  near  the  observer.  In  short,  in  this 
position,  the  major  axis  of  the  heart  follows,  from  back 
to  front,  the  same  direction  as  the  normal  ray.  At  the 
right  the  line  of  the  contour  delimits  the  right  auricle 
above  and  the  right  ventricle  below. 


Tig.  23. 


ORTHODIAGRAM  TAKEN  IN  THE  LEFT  ANTEEIOR 
OBLIQUE  POSITION  AT  50  DEGREES 


OD,  right  auricle;   OG,  left  auricle;  VD,  left  ventricle;   p,  apex  of  the 
heart. 


Lateral  positions.  The  lateral  positions,  right  and  left, 
are  obtained  by  placing  the  patient  in  such  a  way  that 
with  either  the  right  shoulder  or  the  left  shoulder  in  con- 
tact with  the  screen,  the  bi-scapular  axis  forms  an  angle 
of  90  degrees. 

The  cardiac  shadow  is  separated  behind  from  the  verte- 


48 


THE  HEART  AND  THE  AORTA 


bral  column  by  a  narrow,  clear  band;  this  is  the  retro- 
cardiac  clear  space.  In  front  it  is  separated  from  the 
sternal  outline  by  another  clear  band  (Figs.  24  and  25) 
which  is  the  retro-sternal  clear  space. 

This  space  may  be  much  reduced  or  completely  dis- 
appear at  the  lower  part  when  the  heart  is  enlarged  in 
volume  or  when  adhesions  fix  the  mediastinum  to  the 
sternum.  In  the  right  lateral  position  there  is  a  good 
view  of  the  proximal  and  terminal  portions  of  the  arch ; 
in  the  left  lateral,  the  superimposed  dilatations  of  the 
pulmonary  and  aortic  arches  are  seen. 

In  these  positions  it  is  convenient  to  observe  the  outline 
of  the  thorax.  If  during  inspiration  and  during  expira- 
tion the  sterno-abdominal  contours  are  successively 
drawn,  two  lines  are  obtained  perceptibly  parallel  for 
most  of  their  length.  They  meet  only  at  the  level  of  the 
umbilical  region  (Fig  26) .  Wenckebach  has  shown  that  in 
the  case  of  extensive  pericardial  adhesions,  the  amplitude 
and  form  of  these  respiratory  outlines  are  more  or  less 
modified.  Later  reference  will  be  made  to  this  question 
of  cardiac  symphysis. 


Fig.  24.     EIGHT  LATEEAL  POSITION 
A,  ascending  aorta. 


SHADOW  OF  HEART  IN  NORMAL  STATE   49 


Fig.  25.     LEFT  LATEEAL  POSITION 
A,  aorta;  P,  pulmonary  area. 


; 


Fig.  26.  EESPIBATOEY  OUTLINE  (OETHODIAGEAPHIC)  OF  A 
NOEMAL  SUBJECT  . 


Black  line,  forced  expiration;  dotted  line,  deep  inspiration. 


50       THE  HEART  AND  THE  AORTA 

III.     VARIATIONS     OF     THE     PHYSIOLOGICAL     FORM     OF     THE 

HEART 

In  the  preceding  description  we  have  taken  as  a  type 
the  form  of  the  heart  most  common  among  normal  adults 
of  average  weight  and  height.  It  corresponds  to  what 
investigators  call  the  oblique  type.  But,  even  in  the 
physiological  state,  the  form  of  the  heart  can  vary  a  little. 
Two  other  variations  have  also  been  described,  the  hori- 
zontal and  the  vertical.  The  horizontal  heart  rests  more 
on  the  diaphragm  than  the  oblique.  The  vertical  heart  is 
narrower  and  more  elongated  (Fig.  27). 

These  particular  variations  of  the  heart  result  in  slight 
modifications  in  diameter,  which  when  interpreting  the 
tracings  must  be  taken  into  account. 

Most  often  it  is  necessary  to  ascribe  these  different 
forms  of  the  heart  to  a  special  conformation  of  the  thorax. 
The  horizontal  type  of  heart  is  met  with  especially  in 
subjects  of  small  stature  and  short  thorax,  and  the  verti- 
cal type  in  individuals  whose  thorax  is  narrow  and  long. 

The  vertical  or  small  heart  has  been  wrongly  consid- 
ered a  pathological  variation  and  thought  to  be  a  sign  of 
pulmonary  tuberculosis.     It  is  frequently  found  in  this 


Fig.  27.     VEETICAL  HEART 


SHADOW  OF  HEART  IN  NORMAL  STATE       51 

disease,  but  that  is  not  due  to  tuberculosis,  but  to  the  fact 
that  the  tuberculous  usually  have  a  narrow  elongated 
thorax.  The  same  form  of  heart  can  be  found  among 
patients  free  from  tuberculosis,  whose  thorax  has  caused 
the  same  condition. 

There  should  be  mentioned  among  the  physiological 
forms  of  heart  displacement,  that  form  which  has  been 
given  the  name  of  dropping  heart  (Tropfherz,  cor  pendu- 
lum, cuore  a  goccia,  cceur  suspendu).  It  is  well  under- 
stood that  this  displacement  is  quite  different  from  that 
of  cardioptosis,  which  constitutes  a  pathological  varia- 
tion. Cor  pendulum  differs  from  it  in  that  the  heart  is 
not  lowered  as  a  whole,  but  is  simply  held  in  suspension 
by  its  attachments  to  the  vessels  of  the  base  and  to  the 
ligaments  of  the  neck,  the  heart  apex  resting  a  slight 
distance  from  the  diaphragm,  which  drops  below  it,  leav- 
ing a  clear  and  sometimes  rather  broad  band  between  the 
heart  and  diaphragm. 

According  to  Wenckebach,  this  abnormal  configura- 
tion results  from  the  lowering  of  the  insertion  of  the 
diaphragm  coincident  with  an  elongation  of  the  thorax; 
he  thinks,  moreover,  that  it  is  accompanied  by  rhythmic 
lowering  movements  of  the  larynx,  resulting  from  the 
pull  which  the  heart  exerts  on  the  muscles  of  the  larynx 
during  systole.  This  idea,  if  it  is  correct,  would  take 
away  much  of  the  value  of  the  rhythmic  lowering  of  the 
larynx,  or  Oliver's  sign,  which  is  generally  considered  a 
sign  of  aortic  aneurism. 

Two  other  peculiarities  may  be  mentioned,  which  might 
wrongly  be  considered  of  a  pathological  nature,  but  which 
are,  however,  compatible  with  the  normal. 

The  first  consists  of  a  shadow  on  the  diaphragm,  at  the 
level  of  the  attachments  of  the  pericardium,  which  in- 
creases during  deep  inspiration  and  then  takes  on  the 
aspect  of  a  triangle,  the  base  of  which  rests  on  the  dia- 
phragm itself  (Fig.  28). 

This  image  appears  at  first  different  from  that  which 


52 


THE  HEART  AND  THE  AORTA 


is  usually  found.  It  is  admitted  that  the  fibrous  peri- 
cardial sac,  which  is  inserted  over  the  dome  of  the  dia- 
phragm and  adheres  closely  to  the  phrenic  center,  gives 
only  an  inappreciable  shadow  above  the  left  portion  of 
the  diaphragm.  Besides,  this  shadow  disappears  entirely 
in  forced  inspiration,  the  heart  being  then  separated  from 
.the  diaphragm  by  a  clear  space  which  corresponds  to  the 
base  of  the  left  lung  and  the  lower  edge  of  which  is  out- 
lined for  the  greater  part  of  its  length  against  the  clear- 
ness of  the  pulmonary  tissue. 


s^\  r\ 


Fig.  28.  INSERTION  OF  THE  PERICARDIUM  VISIBLE  DURING 
DEEP  INSPIRATION  ON  THE  LEVEL  OF  THE  CARDIO- 
DIAPHRAGMATIC  SINUS 


However,  it  is  not  uncommon  that  instead  of  this  posi- 
tion the  image  represented  in  Fig.  28  is  obtained,  in 
physiological  hearts,  and  in  patients  indiscriminately  fat 
or  thin.  It  is  due,  very  likely,  to  a  certain  thickening  of 
the  pericardial  folds.  Images  produced  by  the  presence 
of  shadows  due  to  pathological  adhesions  can  be  distin- 
guished by  the  fact  that  one  may  there  recognize  the 
inferior  contour  of  the  heart  apex,  always  darker  than 
the  shadow  of  the  pericardial-diaphragmatic  tissues,  and 


SHADOW  OF  HEART  IN  NORMAL  STATE       53 

this  is  ordinarily  impossible  when  adhesions  exist;  on  the 
other  hand,  the  movements  of  the  heart  keep  their  normal 
amplitude  during  respiratory  displacements  and  the 
expansion  of  the  diaphragm. 

The  other  condition  that  might  equally  well  lead  to  a 
false  conclusion  as  to  the  presence  of  adhesions  of  the 
pericardium  is  found  in  certain  obese  patients,  whose  left 
cardio-diaphragmatic  sinus,  instead  of  being  clear,  is 
filled  by  a  shadow,  less  heavy,  it  is  true,  than  that  usually 
cast  by  the  heart.  This  shadow  may  be  due  exclusively 
to  the  existence  of  a  fatty  cushion  surrounding  the  apex 
of  the  heart.  Schwartz9  has  proved  this  by  his  studies  on 
cadavers. 

IV.     PARTICULAR    STUDIES    TO    DETERMINE    VENTRICULAR 
DEVELOPMENT  IN  DEPTH 

The  observation  of  the  heart  in  the  right  posterior 
oblique  position  allows  the  determination  at  what  angle 
the  apex  disappears  behind  the  shadow  of  the  vertebral 
column.  This  angle  determines  the  function  of  the  left 
cardiac  border  outline.  The  goniometer  shows  that  it 
is  small,  25  degrees  for  example,  in  the  case  of  a  vertical 
heart,  and  a  little  greater,  about  30  degrees,  in  the  case 
of  a  horizontal  heart. 

Our  procedure  has  been  subjected  to  some  modifica- 
tion by  several  investigators.  Josue,  Delherm  and  La- 
querriere10  have  used,  instead  of  the  goniometer,  a  revolv- 
ing platform  on  which  the  patient  is  placed,  and  which 
gives  the  degree  of  obliquity  of  the  body.  Beaujard11 
calculates  not  the  angle  at  which  the  apex  disappears,  but 
another  sagitto-spino-ventriculo-tangential,  or  ventricu- 
lar volumetric  angle  which  is  equal  to  it. 

9  G.  Schwartz,  Sur  une  caracteristique  radioscopique  du  cosur  des  ooeses 
et  sa  raison  d'etre  anatomique.     (Wiener  Klin.  Woch.,  1910,  no.  51,  p.  1850.) 

i°  Josue,  Delherm  and  Laquerriere,  Bulletin  de  la  Societe  de  Radiologie, 
1914. 

11  Beaujard,  Bulletin  de  la  Reunion  Medicale  de  la  7e  Region,  15  sept., 
1917. 


54       THE  HEART  AND  THE  AORTA 

In  a  general  way  these  methods  confirm  the  results  at 
which  we  have  arrived;  but  they  necessitate  apparatus 
more  or  less  complicated.  We  have  found  more  simple 
another  procedure  which  gives,  not  the  angle  at  which  the 
apex  disappears  in  the  right  posterior  oblique  position, 
but  a  practical  and  rapid  estimate,  in  depth,  of  the  ven- 
tricular development.  The  calculation  of  the  angle  of 
disappearance  already  gives  us  this  information,  for  it 
is  an  action,  not  only  of  the  outward  push  of  the  apex,  but 
also  of  ventricular  enlargement  behind.  To  this  latter 
factor  preponderant  importance  is  attributed.  We  know 
that  the  left  ventricle  forms  very  little  of  the  anterior 
surface  of  the  heart  and  that  its  position  is,  for  the 
most  part,  deep  and  mediastinal.  The  result  is,  then,  that 
to  diagnose  incipient  ventricular  hypertrophy,  it  is  neces- 
sary to  be  able  to  determine  the  degree  of  enlargement  of 
the  left  ventricle  in  depth. , 

Our  procedure  adopts  the  radioscopic  method  in  plot- 
ting the  depth  of  foreign  bodies.  It  is  based  for  the  most 
part  on  the  relation  of  like  triangles.  The  principal  out- 
lines are  these : 

In  Fig.  29,  let  0  be  the  projectile  to  locate ;  E,  the  radio- 
scopic screen;  A,  the  tube,  which  is  60  centimeters  from 
the  screen.  In  position  A,  the  tube  gives  a  normal  ray 
which  passes  through  the  foreign  body  0,  the  image  of 
which  falls  at  C.  This  first  projection  is  marked  with  a 
crayon  on  the  glass  of  the  screen.  The  tube  is  moved 
from  A  to  A',  a  known  distance,  10  centimeters.  The 
beam  of  rays  reaching  0  projects  the  image  at  C.  This 
is  marked  on  the  glass,  C.  It  is  easy  to  calculate  by 
means  of  a  millimetric  rule  the  distance  CC  which  sepa- 
rates the  two  crayon  marks.  On  the  other  hand,  AC  and 
AA'  are  known.  These  three  elements  allow  the  graphic 
construction  or  the  mathematical  calculation  to  be  made, 
which,  given  the  two  like  triangles  AOA',  COC,  gives  the 
value  OC,  that  is  to  say,  the  distance  of  the  foreign  body 
from  the  screen. 


SHADOW  OF  HEART  IN  NORMAL  STATE       55 

A'  A 


Fig.  29.     FIGUBE  EEPEESENTING  THE   METHOD  OF  DEVIATING 
THE  TUBE  IN  OEDEE  TO  LOCALIZE  FOEEIGN  BODIES 

E,  screen;  AA',  two  positions  of  the  tube;  O,  projectile;  CC,  projections 
of  the  foreign  body. 

By  repeating  the  same  method,  having  for  the  object 
the  apex  of  the  heart  of  a  normal  subject,  and  not  a 
foreign  body,  and  by  bringing  the  ray  AN  tangent  to  it 
(Fig.  30,  black  lines),  a  projection  is  obtained  of  the  apex 
that  is  not  deformed.  Mark  with  a  crayon  on  the  screen 
point  N,  which  coincides  with  the  outer  edge  of  the 
shadow;  then  move  the  tube  10  centimeters  toward  the 
left  of  the  operator.  The  image  of  the  apex  is  seen  to 
have  become  deformed  and  displaced  toward  the  right. 
Mark  a  second  point  (N')  to  fix  the  amplitude  of  the  dis- 
placement.   A  millimetric  rule  allows  of  its  calculation. 

A  case  of  hypertrophy  of  the  left  ventricle  is  presented 
here  as  an  example  (Fig.  30,  contours  and  lines  dotted). 
The  enlargement  in  volume  has  only  a  bearing  on  the 
mediastinal  contour  of  the  left  ventricle.  The  apex  is  not 
pushed  out,  it  occupies  the  same  lateral  position  as  in  the 
physiological  condition  (black  lines).     The  normal  ray, 


56 


THE  HEART  AND  THE  AORTA 


tangent  to  the  apex  of  the  heart,  unites  in  the  two  cases. 
But  when  the  tube  is  moved  the  oblique  ray  meets  the  con- 
tour of  the  left  ventricle  sooner  than  in  a  normal  organ, 
and  it  projects  the  outline  of  it,  not  at  N',  but  at  G',  much 
farther  from  N  than  from  N'.  The  deviation  is  consider- 
able. '  It  shows,  obviously,  an  increase  in  volume  of  the 
left  ventricle  in  depth. 


A  A'       A  A 


Fig.  30 


N  N'DD 
Fig.  31 


Fig.  30.  DIAGRAM  OF  THE  METHOD  FOR  FINDING  THE  INDEX 
OF  DEPTH  IN  CASE  OF  HYPERTROPHY  OF  THE  LEFT  VENTRICLE 

AA',  positions  of  the  tube;  NN',  GG',  projections  of  the  normal  ray  and 
of   the   oblique  ray. 

Fig.  31.     SAME   METHOD   IN   CASE   OF   ENLARGEMENT    OF   THE 
RIGHT   VENTRICLE 

AA',  positions  of  the  tube;    NN',  DD',  projections  of  the  normal  ray 
and   of  the  oblique. 


SHADOW  OF  HEART  IN   NORMAL  STATE        57 

It  will  be  noted  on  the  figure  that  it  is  not  the  depth  of 
the  apex  which  this  method  reveals,  but  the  maximum  of 
salience  of  the  posterior  contour  of  the  heart,  situated 
behind  the  apex  and  in  the  path  of  the  oblique  ray. 
Greater  depth  may  be  present  outside  of  it.  The  process 
then  does  not  give  the  antero-posterior  diameter  of  the 
heart,  but  valuable  indications  as  to  a  point  on  the  pos- 
terior surface  of  the  organ. 

When  the  right  ventricle  alone  is  increased  in  volume, 
the  result  of  the  tube  manipulation  gives  the  following 
(Fig.  31,  contours  and  lines  black  and  dotted) : 

The  normal  ray  ends  at  D,  the  oblique  ray  at  D'.  The 
deviation  is  a  little  greater  than  in  the  case  of  a  physio- 
logical heart,  but  less  considerable  than  in  the  case  of  an 
hypertrophied  left  ventricle.  The  importance  of  the  pro- 
jecture  of  the  apex  does  not  influence  the  oblique  ray.  It 
is  the  depth  of  the  apex  that  determines  the  deviation 
DD';  so  in  the  actual  case,  its  maximum  of  posterior 
salience  is  hardly  more  accentuated  than  in  a  normal  case. 
The  principal  development  of  the  right  ventricle  is  ante- 
rior, and  consequently  is  out  of  the  course  of  the  oblique 
ray. 

In  practice  this  fact  can  be  verified  equally  well  by  the 
calculation  of  the  angle  of  disappearance  of  the  apex  in 
the  right  posterior  oblique.  Beaujard  and  Caillods  have 
pointed  it  out.  In  order  that  the  index  of  depth  be  raised, 
in  cases  of  increase  in  volume  of  the  right  ventricle,  it  is 
necessary  that  the  right  ventricle  press  the  left  ventricle 
down  or  that  the  latter  increase  concurrently  in  volume. 

Definite  information  on  the  enlargement  of  the  right 
ventricle  should  not  be  expected  from  this  procedure. 
The  ordinary  signs  of  the  enlargement  of  this  cavity 
are  sufficient.  On  the  other  hand,  the  method  of  moving 
the  tube  on  the  scale  becomes  extremely  important  when 
it  is  a  question  of  determining  in  depth  the  development 
of  the  left  heart.    When  there  exists  no  other  radioscopic 


58       THE  HEART  AND  THE  AORTA 

indication,  incipient  hypertrophy  of  the  posterior  wall  of 
the  left  ventricle  may  be  recognized  by  it. 

The  technic  is  simple :  the  patient  is  placed  behind  the 
fixed  screen,  60  centimeters  away  from  the  anticathode. 
The  patient  may  be  in  the  prone  or  upright  position.  The 
vertical  position  is  preferred,  as  the  body  is  made  im- 
movable by  the  contact  of  the  anterior  surface  of  the 
thorax  with  the  screen. 

The  method  is  essentially  this:  (1)  center  the  tube  on 
the  apical  region  and  indicate  on  the  glass  with  crayon 
the  extreme  outline;  (2)  place  on  the  screen  a  rule  fur- 
nished with  two  points  10  centimeters  apart.  The  scale 
on  the  right  coincides  with  the  first  crayon  mark  and  with 
the  cardiac  outline;  (3)  move  the  tube  to  the  left  of  the 
observer  until  the  normal  ray  passes  through  the  second 
point  on  the  rule;  (4)  open  the  diaphragm  wide,  raise 
the  rule  and  mark  a  crayon  point  opposite  the  first,  on 
the  new  outline  of  the  apical  area;  (5)  count  the  number 
of  millimeters  that  separate  the  two  crayon  marks. 

The  figure  thus  obtained  shows  the  development  of  the 
heart  in  depth. 

All  the  points  of  the  cardiac  outline  left  and  right  can 
be  investigated  in  the  same  way.  In  normal  subjects  the 
figure  varies  at  the  apex  from  7  to  14  millimeters.  It  is 
generally  about  10.  It  has  the  same  value — sometimes 
1  or  2  millimeters  more — on  the  left  side  toward  the  base. 
At  the  apex  and  at  the  base  it  may  be  raised  to  18,  20,  25, 
and  30  millimeters  in  the  course  of  different  cardiac 
affections. 

V.  SUMMARY  AND  CONCLUSIONS: 

RULES  TO  FOLLOW  IN  RADIOLOGICAL  EXAMINATION  OF  THE 

HEART 

The  details  of  the  radiological  examination  of  the  heart 
being  known,  the  technic  is  as  follows : 

1.     The  first  step  is  the  radioscopic  examination  of  the 


SHADOW  OF  HEART  IN   NORMAL  STATE       59 

heart  as  a  whole.  This  examination,  under  the  fluoro- 
scope,  will  give  a  general  view  of  the  heart,  its  form  as 
well  as  its  relations  to  the  thoracic  cavity  contents  :  lungs, 
pleurae,  pericardium  and  posterior  mediastinum.  The 
patient  will  be  in  the  vertical  position  and  will  in  turn 
present  front,  back  and  oblique  positions  to  the  screen; 
the  latter  positions  will  show  the  degree  of  transparency 
of  the  retro-cardiac  space. 

2.  The  next  step  is  to  take  a  radiogram.  According  to 
the  apparatus  at  one's  disposal,  this  will  be  an  orthodia- 
gram or  a  long-distance  radiogram,  or  better,  both  in  suc- 
cession. These  are  the  first  steps  in  studying  the  heart. 
Its  volume  is  also  determined  by  fixing  the  contour  of  the 
real  projection  of  the  heart  shadow. 

The  patient  will  be  in  the  frontal  position,  upright  or 
prone  as  the  case  may  be,  but  care  should  be  taken  to 
have  him  perfectly  immovable  and  held  in  a  plane  parallel 
to  that  of  the  screen  or  of  the  plate. 

On  the  radiogram  thus  obtained  the  diameters  of  the 
heart  can  be  established,  and  an  examination  made  of 
the  development  of  the  right  and  left  contours,  their  rela- 
tions, the  position  of  the  apex,  its  form  and  its  distance 
from  the  left  contour  of  the  thoracic  cavity. 

3.  The  next  step  is  to  determine  some  points  of  detail. 
For  this  the  orthodiagraphic  method  is  applied,  which 
alone  can  give  special  information  concerning: 

(a)  The  position  of  point  G. 

(b)  The  index  of  the  development  of  the  heart  and 
particularly  of  the  left  ventricle  in  depth. 

(c)  The  amplitude  of  the  respiratory  displacements  of 
the  heart  and  the  diaphragm. 

(d)  The  degree  of  mobility  of  the  apex  of  the  heart. 

(e)  The  development  of  the  inferior  contour  of  the 
heart  observed  during  deep  inspiration. 

(f)  The  nature  of  the  pulsations  which  animate  the 
contours  of  the  heart. 

4.  The  final  step  is  the  examination  of  the  heart  in 


60       THE  HEART  AND  THE  AORTA 

oblique  positions.  The  patient  is  placed  successively  in 
all  the  oblique  positions  described,  so  that  a  more  pre- 
cise analysis  may  be  made  of  the  various  modifications  of 
form  already  studied,  and  especially,  that  the  angle  of 
disappearance  of  the  apex  in  the  right  posterior  oblique 
position  may  be  determined.  In  this  way  the  respective 
increases  in  volume  of  the  different  cardiac  cavities  can 
be  measured,  the  size  of  the  retro-cardiac  clear  space  and 
the  outline  of  the  heart  shadow  at  its  level.  Though  this 
latter  examination  need  not  be  conducted  in  as  regular 
a  manner  as  the  others,  and  though  it  can  be  made  equally 
well  by  radioscopy  or  by  intensive  radiography,  never- 
theless it  is  indispensable  to  know  the  angle  of  obliquity 
at  which  the  patient  was  placed  during  the  examination. 
It  is  unnecessary  to  point  out  that  the  modifications  of 
this  or  that  part  of  the  heart  at  a  given  angle  may  lead  to 
interpretations  which  differ  but  are  always  helpful  in 
diagnosis. 


CHAPTER  III 

THE  SHADOW  OF  THE  HEART  IN  THE  PATHOLOGI- 
CAL STATE 

THE  pathological  changes  in  the  volume  of  the  heart 
are  complete  or  partial:  complete,  when  they  affect 
the  organ  as  a  whole;  partial,  when  they  concern  only 
certain  cardiac  cavities. 

The  shadow  cast  by  the  organ  determines  certain  modi- 
fications which  will  be  studied  with  the  assistance  of  cer- 
tain clinical  facts,  in  order  to  give  examples  instead  of 
diagrams. 

MODIFICATIONS  AFFECTING  THE  WHOLE  HEART 

These  are  shown  by  an  increase  or  diminution  in  the 
surface  of  the  shadow. 

The  estimate  of  the  shadow  as  a  whole  is  made  by 
measuring  its  area  (by  means  of  Amsler's  planimeter 
or  millimetric  ruled  paper)  and  the  diameters  of  the  pro- 
jection. This  double  measurement  is  necessary  because 
the  diameters  may  change  in  the  same  patient,  according 
to  the  different  phases  of  the  disease,  without  any  varia- 
tion in  the  total  surface. 

Sufficiently  precise  data  are  had  from  a  first  examina- 
tion to  judge  whether  the  heart  shadow  of  a  patient  is 
increased  or  diminished  in  volume.  Moritz,  Dietlen, 
Groedel,  Claytor  and  Merrill  have  drawn  up  tables  of 
normal  areas  and  diameters  according  to  age,  height, 
weight  and  sex;  these  will  be  merely  referred  to,  care 
being  taken  to  compare  the  figures  with  those  of  the 


62       THE  HEART  AND  THE  AORTA 

tracings  taken  in  the  same  positions,  for  the  diameters 
vary  according  as  the  patient  is  examined  in  the  upright 
or  prone  position. 

According  to  Dietlen12  the  volume  of  the  heart  is  in- 
creased as  soon  as  a  tracing  exceeds  the  normal  corre- 
sponding tracing  by  five  millimeters  for  the  diameters 
and  five  square  centimeters  for  the  area ;  it  is  diminished 
when  the  measurements  are  less  than  those  which  corre- 
spond to  the  smallest  normal  tracings  taken  in  the  same 
conditions  of  position,  age,  weight,  and  sex. 

These  deductions,  however,  should  not  be  accepted 
without  reservation,  and  if  the  orthodiagraphic  method 
is  sufficiently  accurate  clinically,  it  is  far  from  having, 
even  in  experienced  hands,  a  geometric  precision.  Al- 
most always,  moreover,  modifications  affecting  the  whole 
heart  are  transitory  and  it  is  rather  from  the  comparison 
of  several  serial  tracings  taken  at  different  intervals  in 
the  same  patient  that  conclusions  can  be  drawn,  and,  in 
general,  it  is  sufficient  to  superimpose  the  tracings  in 
order  to  read  the  changes  in  volume.  The  list  of  succes- 
sive measurements  of  areas  and  diameters  explains 
equally  well  the  anatomical  pathological  variations  in  the 
heart  volume. 

Increases  in  the  heart  as  a  whole  are  met  with  espe- 
cially in  the  course  of  infectious  diseases :  diphtheria, 
pneumonia,  typhoid  fever  (Dietlen).  They  are  particu- 
larly important  in  cases  of  myocarditis.  Fig.  32  shows 
the  successive  contours  of  the  shadow  of  the  heart  in  a 
man  of  forty-four  with  very  severe  alcoholic  myocarditis, 
benefited  by  intravenous  injections  of  strophanthine3 
The  line  in  dots  and  dashes  gives  the  image  of  the  heart 
before  treatment ;  the  dotted  line,  the  result  after  the  first 
injection;  the  black  line  shows  the  cardiac  shadow  when 

12  Dietlen,  Munch.  Med.  Woch.,  6  October,  1908. 

13  Vaquez  et  Leconte,  Les  injections  intra-veineuses  de  strophantine  dans 
le  trait ement  de  1  'insuffisanee  eardiaque.  (Soc.  med.  des  hopitaux,  26  mars, 
1909.) 


HEART  IN  THE  PATHOLOGICAL  STATE 


63 


Fig.  32.     ALCOHOLIC  MYOCAEDITIS 

By  comparing  the  three  superimposed  tracings  marked  by  different  lines, 
one  can  follow  the  progressive  decrease  in  the  volume  of  the  heart  under 
treatment.  The  tracing  in  black  lines  was  taken  the  day  the  patient  left 
the  hospital. 

finally,  three  months  later,  the  patient  left  the  hospital 
cured. 

The  diameters  and  areas  were : 


Area 

Longitudinal 

Diameter 

in  cm. 

Horizontal 

Diameter 

in  cm. 

October  29,  1908 

November  4,  1908 
January  28,  1909 

168om2 
159cm2 
132em2 

17.7  cm. 

17.7  cm. 

15.8  cm. 

18.    cm. 
17.5  em. 
15.3  cm. 

PARTIAL  MODIFICATIONS 

The  ascertaining  of  partial  modifications  in  the  volume 
of  the  heart  is  more  important  than  determining  modifi- 
cations in  the  heart  as  a  whole,  for  valuable  information 
is  had  as  to  the  reaction  of  the  different  cavities  of  the 
organ  upon  its  organic  lesions. 


64       THE  HEART  AND  THE  AORTA 

I.     DETERMINATION  OF  THE  TOTAL  VENTRICULAR 
VOLUME 

The  increase  in  volume  of  the  two  ventricles  is  shown 
by  the  abnormal  development  of  the  outline  in  the  left 
pulmonary  field  on  a  cardiogram  taken  in  the  frontal 
position. 

In  this  case  the  apex  is  pushed  out  toward  the  thoracic 
wall,  which  it  sometimes  touches.  Moreover,  it  is  de- 
pressed and  may,  in  certain  cases,  be  seen  only  at  two  or 
three  and  more  centimeters  below  the  diaphragm  in  deep 
inspiration.  Its  form  becomes  rounded  or  globulous. 
The  longitudinal  diameter  is  elongated,  sometimes  18  to 
20  centimeters  and  more,  and  the  horizontal  diameter 
increases,  especially  in  that  portion  which  meets  the  left 
border.  This  border  is  longer  on  account  of  the  apex 
being  lowered,  the  area  of  origin  elevated  (point  Gr),  and 
the  external  convex  curve  accentuated. 

The  importance  of  the  ventricular  area  may  be  equally 
well  determined  by  another  more  rapid  method,  which 
consists  in  finding  under  what  angle  of  obliquity  of  the 
body  the  heart  shadow  disappears  behind  the  vertebral 
column  shadow  in  the  right  posterior  oblique  position. 
In  a  normal  subject  it  ceases  to  be  visible  at  an  angle  of 
30  degrees  on  an  average.  This  examination  is  made 
before  a  fixed  screen,  keeping  the  normal  ray  tangent  to 
the  apex  and  making  use  of  a  movable  back  which  indi- 
cates the  angle  of  obliquity  of  the  body.  The  disappear- 
ance of  the  cardiac  shadow  behind  the  vertebral  column 
at  an  angle  of  obliquity  of  40  degrees  or  more  warrants 
the  conclusion  that  the  ventricular  area  is  increased  in 
volume14  in  proportion  to  the  increase  in  the  angle.  "We 
have  seen  it  exceed  65  degrees  in  certain  cases  of  aortic 
insufficiency. 

i*It  is  evident  that  these  considerations  cease  to  be  exact  if,  for  reasons 
independent  of  the  variations  in  the  volume  proper  of  the  heart,  such  as 
pleural  adhesions,  effusions,  etc.,  the  organ  is  displaced  either  to  the  right 
or  to  the  left  of  its  vertical  axis,  or  depressed  in  depth. 


HEART  IN  THE  PATHOLOGICAL  STATE        65 

The  tracings  in  Figs.  33  and  34  are  of  a  man  of  forty- 
eight,  1  m.  68  cm.  in  height,  suffering  from  mitral  dis- 
ease, with  easily  provoked  dyspnoea,  pulse  small  and 
arhythmic.  Examination  in  frontal  position,  prone 
(Fig.  33),  shows  that  the  apex  is  pushed  out  and  lowered 
(by  palpation,  pulsation  was  felt  in  the  sixth  intercostal 
space) ;  the  longitudinal  diameter  measures  17  centi- 
meters (normal  average  at  this  height,  13  to  14  centi- 
meters) ;  the  horizontal  diameter  is  15.9  cm.  (average, 
13  to  14  centimeters),  the  middle  arc  is  exaggerated  and 
the  point  Gr  is  lowered ;  finally,  in  right  posterior  oblique 
position  (Fig.  34)  the  ventricular  shadow  is  still  visible 
50  degrees  to  the  left ;  it  disappears  behind  the  vertebral 
column  only  at  an  angle  of  55  degrees. 


Fig.  33.     INSUFFICIENCY  AND  MITRAL  CONTRACTION 

The  exaggerated  development  as  seen  on  this  tracing  is  due  to  the  in- 
crease in  the  volume  of  the  two  ventricles. 

In  analogous  cases  we  can  estimate  the  development 
of  the  ventricles  in  depth  by  using  the  method  with  the 
tube  on  a  sliding  scale,  as  has  been  described.  The  index 
figure  in  the  case  of  right  and  left  ventricular  enlarge- 
ment, but  especially  left,  rises  to  20,  25  millimeters  and 
more.  If  hypertrophy  of  the  right  ventricle  is  predomi- 
nant, the  index  remains  nearly  normal. 


66       THE  HEART  AND  THE  AORTA 

It  will  be  of  interest  therefore  to  examine  the  ortho- 
diagraphic  data  relative  to  the  modifications  in  volume 
of  each  of  the  cardiac  cavities. 


Fig.    34.      SAME    HEAET    AS   IN   FIG.    33,    IN   EIGHT    POSTERIOR 
OBLIQUE  POSITION 

At  50  degrees  the  ventricular  area  has  not  yet  disappeared  behind  the 
vertebral  column. 


II.     LEFT  VENTRICLE 

Clinically  this  is  a  typical  case  of  left  ventricular 
hypertrophy.  Fig.  35  is  of  a  patient  thirty-three  years 
of  age,  weighing  67  kilos,  height  1  m.  71  cm.,  suffering 
from  aortic  insufficiency  with  compensation.  The. first 
important  point  in  this  figure  is  that  the  apex  of  the 
heart  is  pushed  outward  only  a  little,  but  it  falls  below 
the  diaphragm  even  during  deep  inspiration.  The  hori- 
zontal diameter  measures  12.8  cm.  and  the  longitudinal 
diameter,  13.5  cm.  By  referring  to  Moritz's  tables,  the 
longitudinal  diameter  for  a  man  1  m.  71  cm.  in  height 
would  be  12.5  cm.  It  is  increased  then  by  one  centimeter. 
On  the  other  hand,  the  horizontal  diameter  remains  in 
this  case  nearly  normal.  Point  Gr  is  raised,  the  general 
form  of  the  left  contour  is  modified,  its  convexity  is 
accentuated,  the  apex  of  the  heart  is  rounded. 


HEART  IN  THE  PATHOLOGICAL  STATE 


G7 


In  the  right  posterior  oblique  position  the  cardiac 
shadow  disappears  behind  the  vertebral  column  at  an 
angle  of  40  degrees.  The  index  in  depth  exceeds  15  milli- 
meters. The  conclusion  is  plain :  the  ventricular  volume 
is  exaggerated.  Oblique  examination  and  examination 
in  depth  complete  the  data  of  the  tracings  made  in  the 
frontal  position,  especially  in  cases  in  which  anatomical 
changes  are  not  marked.  It  is  understood,  moreover, 
that  in  the   right  posterior   oblique  position  the   least 


Fig.    35.      HYPERTROPHY    OF    THE    LEFT    VENTRICLE     (AORTIC 
INSUFFICIENCY) 

The  apex  of  the  heart  is  at  G',  lowered,  rounded,  the  left  ventricular  out- 
line GG'  is  elongated. 

changes  in  volume  of  the  left  ventricle  are  easily  seen. 
This  cavity  corresponds  especially  to  the  posterior  part 
of  the  organ ;  when  it  increases,  it  does  so  not  only  toward 
the  left,  but  also  in  its  antero-posterior  diameter.  As  it 
is  the  projection  of  the  postero-lateral  contour  of  the  left 
ventricle  which  is  shown  on  the  screen  in  the  right  poste- 
rior oblique  position,  it  is  quite  natural  that  this  shadow, 
when  it  corresponds  to  an  enlarged  cavity,  should  dis- 
appear slowly.  It  is  also  understood  that  in  finding  the 
index  in  depth,  the  oblique  ray  encounters  the  contour 


68 


THE  HEART  AND  THE  AORTA 


of  the  Heart  lower  down  and  projects  the  shadow  of  it 
further  toward  the  left. 

When  the  hypertrophy  of  the  left  ventricle  is  more 
pronounced,  the  apex  is  pushed  further  out  and  lower, 
the  contour  of  the  left  border  is  more  convex  and  longer, 
the  heart  takes  the  shape  of  a  pear,  as  described  by 
Destot  and  Arcelin  ;15  the  elongation  of  the  diameters  in- 
creases, the  angle  of  disappearance  of  the  apex  in  the 
right  posterior  oblique  position  is  larger,  as  also  the 
index  in  depth. 


n  r> 


Fig.   36.     CONGENITAL  PULMONAEY   STENOSIS 

The  right  ventricle,  alone  increased  in  volume,  rests  on  the  left  diaphragm, 
which  it  depresses;  the  left  ventricle  is  pushed  up  and  outward,  the  apex  is 
seen  at  P  (heart  in  the  form  of  a  "sabot"). 


III.     RIGHT  VENTRICLE 

This  will  be  taken  as  an  example  of  an  affection  in 
which  the  left  ventricle  ordinarily  keeps  its  normal  vol- 
ume, while  the  right  ventricle  is  greatly  enlarged,  as 
occurs  in  lesions  of  the  pulmonary  artery. 

Fig.  36  represents  the  frontal  projection  in  the  prone 
position  of  a  heart  of  a  child  fourteen  years  of  age  with 
congenital  pulmonary  stenosis  accompanied  by  marked 
cyanosis  and  dyspnoea.  In  a  general  way  a  notable 
arterial  saliency  is  observed  due  to  the  dilatation  of  the 
pulmonary  artery  (Pul)  and  a  considerable  enlargement 

is  Arcelin,  Les  formes  de  I  'aire  de  projection  du  cceur  patliologique. 
Lyon,  1906. 


HEART  IN  THE  PATHOLOGICAL  STATE        69 

of  the  right  ventricle.  In  detail  the  tracing  is  analyzed 
as  follows : 

The  longitudinal  diameter  measures  12.5  cm.,  which 
is  too  much  for  a  child  of  fourteen ;  the  horizontal  diame- 
ter is  still  greater,  13.2  cm.  The  apex  (P)  is  pushed  out- 
ward and  raised.  On  this  account  the  position  of  the  left 
ventricle,  (Gr)  is  higher  than  normal,  but  the  total  length 
of  the  ventricular  contour  keeps  its  usual  dimensions 
(7.3  cm.).  Moreover,  its  double  undulation  is  not  modi- 
fied. 

The  shadow  thus  formed  at  the  apex  belongs  to  the 
right  ventricle,  the  lower  border  of  which  can  be  followed 
below  the  diaphragm.  When,  as  is  not  unusual,  it  is 
difficult  to  fix  the  outline  by  a  simple  examination  on  the 
screen,  it  can  be  done  more  surely  by  giving  the  patient 
two  solutions  in  succession :  one  of  bicarbonate  of  soda, 
the  other  of  citric  acid,  which  forming  a  gas  render  the 
stomach  transparent.  If  this  contour  were  that  of  the 
left  ventricle  it  would  have  a  more  vertical  direction  and 
the  apex  would  hang  like  the  bottom  of  a  purse,  whereas 
here  the  form  of  the  cardiac  shadow  resembles  somewhat 
that  of  a  "sabot." 

The  enlargement  of  the  right  ventricle  is  seen  on  the 
right  by  an  exaggeration  of  the  outline  in  its  lower  third 
below  the  auricle.  To  make  sure  that  it  is  the  ventricle 
and  not  the  auricle  which  projects  at  this  level,  take  the 
patient's  pulse  and  note  that  each  radial  pulsation  coin- 
cides-with  the  systolic  retraction  of  the  shadow  in  the 
region  examined,  whereas  the  pulsation  would  be  pre- 
systolic if  it  were  a  question  of  the  auricle. 

Further  than  that,  the  same  outline  of  the  shadow  at 
the  right  of  the  sternum  can  be  found  in  cases  in  which 
the  ventricle,  not  increased  in  volume,  is  only  pressed 
toward  the  right  by  the  hypertrophied  left  ventricle. 
But  this  compression  is  not  accompanied  by  signs  which 
show  the  enlargement  of  the  right  ventricle,  the  lengthen- 
ing of  the  diameters,  especially  the  horizontal,  the  push- 


TO 


THE  HEART  AND  THE  AORTA 


ing  outward  and  elevation  of  the  apex  and  the  lowering 
of  the  inferior  contour  of  the  heart. 

In  left  anterior  oblique  position  an  outline  is  obtained 
which  confirms  the  preceding  data.  By  referring  to  Fig. 
37,  the  line  of  contour  of  the  heart,  situated  at  the  left  of 
the  image,  limits  the  right  auricle  above,  then  the  right 
ventricle  as  far  as  the  diaphragm.  The  shadow  is  seen 
to  be  very  markedly  increased,  which  corresponds  to  the 
enlargement  in  volume  of  the  right  ventricle.  The  dotted 
line  indicates  schematically  the  normal  contour  in  this 
position.  Finally,  in  the  right  posterior  oblique  position 
the  angle  of  disappearance  of  the  apex  cannot  be  exag- 
gerated. It  has  been  seen  that  the  projection  of  the  apex 
toward  the  left  is  not  enough  in  itself  to  increase  this 
angle  and  that  it  is  necessary  that  the  development  of 
the  area  in  depth  be  increased  in  order  that  this  take 
place.  The  determining  of  the  index  leads  to  the  same 
results,  on  the  left,  at  least.  In  cases  where  the  right 
ventricle  projects  toward  the  right  and  pushes  the  auricle 
up,  the  index  in  depth  may  be  exaggerated  on  the  right, 
while  it  is  normal  or  nearly  so  at  the  apex. 


Fig.  37.  LEFT  ANTERIOR  OBLIQUE  POSITION,  50  DEGREES 
The  beam  of  x-rays  penetrates  the  right  back  and  comes  out  in  the  left 
mammillary  zone,  thus  following  the  large  axis  of  the  heart.  At  the  left  of 
the  figure,  and  consequently  in  the  right  lung,  the  outline  of  the  right 
ventricle  (VD)  is  seen,  the  shadow  of  which  forms  a  considerable  salience 
below  the  right  auricle  (OD).  The  dotted  line  indicates  the  normal  ven- 
tricular contour. 


HEART  IN  THE  PATHOLOGICAL  STATE        71 


IV.     LEFT  AURICLE 

It  is  in  the  oblique  positions  that  the  degree  of  develop- 
ment of  the  left  auricle  can  best  be  studied. 

In  the  right  posterior  oblique,  as  in  the  left  anterior 
oblique,  the  normal  ray  passing  the  posterior  mediasti- 
num is  tangent  to  the  margin  of  the  left  auricle. 

When  this  auricle  is  hypertrophied  or  dilated,  its  con- 
tour develops  behind  and  to  the  left  of  the  heart  and 
projects  its  shadow  for  some  distance  into  the  clear  retro- 
cardiac  space.  The  degree  of  enlargement  of  the  auricu- 
lar shadow  is  naturally  proportional  to  the  enlargement 
of  the  cavity.  This  deformation  is  very  characteristic 
in  simple  mitral  stenosis.  However,  the  same  obscurity 
of  the  retro-cardiac  clear  space  may  be  produced  by  the 
presence  of  easily  recognizable  pathological  pulmonary 
or  pleural  shadows,  or  by  a  considerable  augmentation  in 
the  volume  of  the  ventricle,  which,  besides,  is  rare  in 
cases  of  mitral  stenosis. 

Fig.  38  illustrates  a  typical  case  of  hypertrophy  of  the 
left  auricle  in  right  posterior  oblique  position  at  50  de- 


FiG.  38 


Fig.  39 


Fig.  38.     SIMPLE  MITRAL  STENOSIS 

Right  posterior  oblique  position  at  50  degrees.     The  much  enlarged  left 
auricle  casts  a  shadow  which  obscures  part  of  the  retro-cardiac  clear  space. 

Fig.  39.     SAME  CASE,  IN  LEFT  ANTERIOR  OBLIQUE  POSITION  AT 

50  DEGREES 


72       THE  HEART  AND  THE  AORTA 

grees.  The  salience  which  is  noticed  here  and  which  lies 
in  the  postero-superior  part  of  the  cardiac  shadow  can 
only  correspond  to  the  left  auricle;  in  the  retro-cardiac 
clear  space  there  is  only  a  small  transparent  triangle 
included  between  the  ventricular  contour,  the  vertebral 
column  and  the  diaphragm. 

Examination  in  the  left  anterior  oblique  position  leads 
to  identical  proofs  and  conclusions  (Fig.  39). 

The  frontal  position,  without  giving  the  same  precise 
details,  indicates,  nevertheless,  an  increase  of  the  median 
arc,  especially  manifest  in  its  inferior  portion  which  is  at 
once  salient  and  lowered  in  the  region  corresponding  to 
the  auricle  (see  Fig.  44.    Mitral  stenosis). 

V.     RIGHT  AURICLE 

The  favorable  position  for  the  examination  of  the  right 
auricle  is  the  frontal,  the  oblique  positions  being  only 
accessory.. 

In  the  frontal  position  the  right  auricle  is  in  outline  at 
the  right  of  the  sternum  and  its  salience  is  increased  as 
the  auricle  is  increased  in  volume. 

It  is  in  the  superior  portion  of  its  contour  (at  the  level 
of  the  arrow  in  Fig.  40)  that  it  can  best  be  observed,  for 
the  right  ventricle  may,  if  it  is  hypertrophied  or  dilated, 
be  noted  projecting  on  the  right  side,  but  in  the  lower 
third  or  half  of  the  shadow.  In  such  circumstances,  the 
auricle,  pressed  back  and  up,  is  visible  only  in  the  neigh- 
borhood of  the  superior  vena  cava.  There  is  consequently 
always  good  reason  for  studying  it  in  this  high  position. 
In  case  of  doubt,  the  rhythms  of  the  pulsations  determine 
whether  it  is  the  auricle  or  the  ventricle :  the  movements 
of  presystolic  retraction  are  due  to  the  auricle,  the  move- 
ments of  systolic  retraction  to  the  ventricle. 

Figs.  40,  41,  and  42  show  a  case  of  tricuspid  insuffi- 
ciency in  which  the  right  auricle  is  abnormally  developed. 

In  Fig.  40,  frontal  position,  will  be  noted  the  marked 


HEART  IN  THE  PATHOLOGICAL  STATE        73 

development  of  the  right  heart  area  and  the  exaggeration 
of  its  curve  in  the  upper  half.  In  this  place  (at  the  level 
of  the  arrow)  there  were  visible  on  the  screen  very  clear 
movements  of  presystolic  retraction  which  can  be  due  to 
the  auricle  only. 

Fig.  41,  taken  in  the  left  posterior  oblique  position  at 
50  degrees,  shows  that  the  shadow  of  the  right  auricle 
effaces  a  part  of  the  retro-cardiac  clear  space. 


Fig.  40.     TRICUSPID  INSUFFICIENCY 

In  frontal  position  the  shadow  of  the  right  auricle  is  much  enlarged, 
especially  in  the  zone  indicated  by  the  arrow. 

Finally,  in  left  anterior  oblique  position  (Fig.  42)  the 
contour  of  the  right  auricle  describes  a  curve  of  large 
diameter  projecting  over  the  shadow  of  the  right  ven- 
tricle, which  is  contrary  to  what  has  been  described  in 
Fig.  37,  where  the  ventricle  is  very  large  in  relation  to 
the  auricle. 

Sometimes  the  shadow  of  the  right  auricle  may  be  in- 
creased without  a  corresponding  increase  in  the  volume 
of  this  cavity.  This  is  a  fact  observed  in  mitral  stenosis. 
It  is  explained  by  the  elevation  of  the  right  cavities  and 
their  closeness  to  the  sternum  as  a  result  of  the  marked 
development  of  the  left  auricle.     The  obliquity  of  the 


74       THE  HEART  AND  THE  AORTA 

heart  from  back  to  front  is  diminished ;  the  projection  of 
the  auricle  is  increased  as  a  result  of  the  displacement  of 
the  organ  and  not  because  of  its  increase  in  volume. 


Fig.  41  Fig.  42 


Fig.  41.    SAME  CASE  AS  PBECEDING  FIGUBE,  IN  LEFT  POSTEKIOE 
OBLIQUE  POSITION  AT  50  DEGEEES 

In  this  position  the  shadow  of  the  enlarged  right  auricle  merges  with  the 
shadow  of  the  vertebral  column. 

Fig.  42.     SAME   HEAET  AS   IN  FIGS.   40   AND   41,   BUT   IN  LEFT 
ANTEEIOE  OBLIQUE  POSITION  AT  50  DEGEEES 

The  outline  of  the  enlarged  right  auricle  (OD)  makes  a  greater  salient 
in  the  right  lung  than  the  left  ventricle. 

The  preceding  considerations  concern  the  partial  modi- 
fications in  the  volume  of  the  heart  in  connection  with  the 
enlargement  of  one  or  another  of  the  cavities.  But  it  fre- 
quently happens  in  practice  that  several  cavities  are  in- 
volved at  the  same  time  and  to  an  unequal  degree.  New 
images  then  result,  in  which  the  radioscopic  signs  are 
combined.  The  study  of  these  images  gives,  as  will  be 
seen  presently,  valuable  assistance  in  the  diagnosis  and 
the  prognosis  of  a  large  number  of  cardiac  diseases. 


CHAPTER  IV 

VALVULAR  AFFECTIONS 

VALVULAR  lesions  produce  on  the  exterior  form, 
of  the  heart  characteristic  changes  which  are  well 
known  to  pathologists.  These  lesions  can  often  be  inter- 
preted during  the  life  of  the  patient  and  most  clinicians 
can  readily  distinguish  at  first  sight  a  "mitral  lesion" 
from  an  "aortic  lesion."  Sometimes  they  are  not  suffi- 
ciently characteristic  to  be  obtained  by  the  usual  methods 
of  diagnosis.  The  progress  of  radiography  has  been  such 
that  it  has  given  the  means  of  demonstrating  the  deforma- 
tions of  the  cardiac  outline  even  to  the  slightest  detail 
and  furnishing  precise  information  for  the  diagnosis  of 
valvular  lesions. 

SIMPLE  MITRAL  STENOSIS 

Radiological  diagnosis  of  mitral  stenosis  rests  on  two 
principal  points :  the  volume  of  the  left  ventricle  on  the 
one  hand,  and  that  of  the  corresponding  auricle  on  the 
other.  The  positions  favorable  for  estimating  them  are : 
the  direct  anterior  and  the  oblique. 

EXAMINATIONS    IN    THE    DIEECT    ANTERIOR    POSITION 

Orthodiagrams  of  the  heart  in  the  frontal  position  or 
the  direct  anterior  offer  typical  characteristics  which  are 
(see  Fig.  43)  : 

1.  A  considerable  development  of  the  left  median  arc, 
especially  marked  in  the  inferior  portion. 

2.  A  left  ventricular  outline  of  slight  dimension. 

3.  A  modification  of  the  right  contour,  by  an  exaggera- 


76       THE  HEART  AND  THE  AORTA 

tion  of  the  shadow  to  the  right  and  by  raising  of  its 
extreme  points  D  and  D'. 

Left  median  arc.  Examination  of  the  mediastinal 
shadow  outline  on  the  left,  from  the  clavicle  to  the  dia- 
phragm, shows  that  in  most  cases  of  mitral  stenosis,  the 
line  of  contour,  after  having  marked  the  aortic  half  circle, 
takes  an  oblique  direction  from  within  outward  to  the 
heart  apex.  The  outline  shows  only  a  notch,  sometimes 
hardly  perceptible,  which  corresponds  to  point  G,  at  the 
level  of  which  is  observed  the  general  seesaw  movement 
of  which  this  point  constitutes  the  fixed  axis.  The  phe- 
nomenon is  here  perfectly  clear. 

The  point  Gr  lies  lower  than  normal;  it  is  much  below 
point  D  which  is  opposite  to  it.  The  line  which  rises  from 
Gr  to  the  aortic  arc  thus  limits  the  median  arc  which  is 
exaggerated.  The  upper  two-thirds  of  the  outline,  which 
constitutes  the  portion  relatively  the  least  salient,  corre- 
sponds to  the  pulmonary  artery  and  shows  systolic  move- 
ments of  expansion;  the  lower  third  of  the  median  arc, 
which  bulges  the  most,  corresponds  to  the  left  auricle  and 
has  only  very  feeble  pulsations. 

Left  ventricular  outline.  The  line  GGr'  which  limits  the 
shadow  of  the  left  ventricle  is  rather  short  and  does  not 
present,  in  most  cases,  a  convexity  as  marked  as  in  the 
normal  state.  The  slight  distension  of  this  cavity  ex- 
plains why  there  is  a  decreased  convexity  of  the  walls. 

Apex  of  the  heart.  The  apex  is  near  the  left  diaphragm. 
It  generally  appears  as  a  rather  acute  angle,  which  leads 
Destot  to  state  that  in  mitral  stenosis  "the  apex  of  the 
heart  is  pointed. "  It  is  the  more  so,  the  greater  the  ste- 
nosis, and  the  smaller  the  left  ventricle;  when  the  ste- 
nosis is  not  very  pronounced,  the  apex  is  slightly  rounded 
as  in  the  normal.  It  is  always  distinctly  separated  from 
the  left  thoracic  contour,  and  is  often  pushed  a  little  more 
inward  and  downward  than  in  the  normal  state,  but  it 
does  not  follow  from  that  that  the  ventricular  contour 
is  elongated,  for  point  Gr,  where  the  ventricular  contour 


Fig.   44.      TELEEADIOGEAPH   OF   SIMPLE    MITEAL    STENOSIS 


VALVULAR  AFFECTIONS 


77 


begins,  is  itself  lowered,  so  that  the  total  length  of  the 
line  GG'  does  not  change. 

Right  contour.  The  area  of  projection  of  the  heart 
extends  very  noticeably  beyond  the  right  edge  of  the 
sternum.  Its  contour  is  shown  by  a  curved  line  which 
deviates  from  the  sternum  at  its  origin  (point  D)  and 
approaches  it  again  near  the  diaphragm  (point  D'). 

The  right  heart  outline  often  takes,  below  D',  a  vertical 
direction  to  the  diaphragmatic  shadow;  it  then  limits  the 
shadow  of  the  inferior  vena  cava  which  is  more  visible 
than  in  the  normal  state. 


Fig.  43.     SIMPLE  MITRAL  STENOSIS.     WOMAN  52  YEAES  OF  AGE 


The  length  of  the  line  DD'  is  generally  greater  than 
normal.  By  comparing  it  to  the  length  of  the  left  outline 
GG',  the  relation  of  the  two  sides  of  the  heart  is  estab- 
lished. Now,  GG'  is,  in  a  normal  subject,  greater  than 
DD',  whereas  in  simple  mitral  stenosis  GG'  but  slightly 
exceeds,  equals,  or  is  even  less  than,  DD'. 

Diameters.  The  longitudinal  diameter  is  usually  exag- 
gerated; this  is  due  in  part  to  the  elevation  of  point  D 
and  in  part  to  the  lowering  of  the  apex. 

As  for  the  horizontal  diameter,  it  is,  in  spite  of  the 
development  of  the  right  area,  always  much  less  than  the 
longitudinal  diameter. 


78       THE  HEART  AND  THE  AORTA 

Clinical  Cases.  The  diagrams  which  are  published  here 
are  always  comparable  one  with  another. 

Figs.  43  and  45  are  cases  of  marked  mitral  stenosis. 
All  the  points  emphasized  in  the  foregoing  are  found,  and 
here  radiology  only  serves  to  confirm  clinical  findings. 

Fig.  43  is  of  a  woman  fifty-two  years  of  age,  suffering 
from  right  hemiplegia  with  aphasia,  supervening  in  the 
course  of  mitral  stenosis,  the  diagnosis  of  which  had  al- 
ready been  made  by  Duroziez.  Palpation  gave  a  presys- 
tolic thrill  very  clear  in  the  region  of  the  apex ;  ausculta- 
tion, a  rhythm  typical  of  mitral  stenosis :  diastolic  rumble 
with  presystolic  reinforcement,  the  first  sound  rough,  the 
second  diminished.  Further,  percussion  in  the  back,  at  the 
level  of  the  left  scapula  gave  rise  to  that  peculiar  pain, 
or  auricular  stitch  in  the  side,  which  one  of  us  has  noted 
in  patients  with  this  affection. 

The  cardiogram  shows  in  frontal  position  a  marked 
increase  in  the  median  arc,  whereas  the  outline  of  the  left 
ventricle  is  almost  normal.  The  area  of  the  right  auricle 
is  exaggerated;  the  longitudinal  diameter  measures  14.5 
cm.  and  the  horizontal  diameter,  12.6  cm.  Finally,  exami- 
nation in  the  oblique  position  shows  an  increase  in  volume 
in  the  left  auricle. 

Fig.  45  is  that  of  a  young  man  twenty-four  years  of  age 
of  frail  constitution,  affected  from  infancy  with  mitral 
stenosis.  This  had  caused  an  almost  constant  cyanosis 
of  the  extremities  and  dyspnoea  so  severe  that  the  patient 
had  to  abandon  his  profession  of  violinist.  Objective 
examination  gave  a  marked  presystolic  thrill,  and  auscul- 
tation the  characteristic  signs  of  the  lesion. 

The  cardiogram  shows  a  very  marked  lowering  of  point 
G.  The  ventricular  contour  is  almost  vertical,  but  instead 
of  being  convex  it  is  slightly  concave.  The  left  outline, 
GG',  measures  8  cm. ;  the  right,  DD',  is  longer,  measuring 
9  cm. ;  the  longitudinal  diameter  is  15  cm.  and  the  horizon- 
tal 12.6  cm. 

Fig.  46  is  of  a  child  eight  years  of  age,  with  simple 


VALVULAR  AFFECTIONS 


79 


mitral  stenosis.  The  stenosis  was  of  recent  date.  The 
cardiogram  nevertheless  is  absolutely  typical,  showing 
that  the  lesion,  though  barely  established,  already  had 
given  the  usual  characteristics. 

Fig.  47  is  still  more  interesting.  No  heart  affection 
was  suspected  by  subjective  signs  and  only  auscultation 
gave  a  mitral  rhythm,  difficult  to  interpret,  but  sug- 
gesting a  lesion.  But  it  was  unmistakably  present  as  a 
radiological  examination  proved.  The  diagram  demon- 
strates the  exaggerated  saliency  of  the  median  arc,  the 
lowering  of  point  Gr,  and  the  excessive  development  of 


Fig.  45.    SIMPLE  MITEAL  STENOSIS,  MAN  24  YEAES  OF  AGE 


Fig.  46.     SIMPLE  MITEAL  STENOSIS,  CHILD  8  YEAES  OF  AGE 


80 


THE  HEART  AND  THE  AORTA 


the  right  side  of  the  heart.  However,  the  apex  of  the 
organ  is  less  acute  than  in  the  preceding  cases.  The  left 
ventricular  contour  is  a  little  convex  as  in  the  normal, 
but  the  relation  of  the  outlines  and  the  diameters  is  none 
the  less  modified  in  the  manner  expected.  The  left  side, 
GG',  measures  8  cm.,  whereas  the  right  side,  DD',  meas- 
ures 9.5  cm.  The  diameters  are:  longitudinal,  13  cm., 
horizontal,  8  cm. 


Fig.    47.      SIMPLE    MITRAL    STENOSIS,    NOT    SEVERE.      MAN    33 

YEARS  OF  AGE 

Interpretation  of  cardiograms  and  comparison  with 
percussion.  In  the  great  majority  of  cases  the  tracings 
obtained  by  percussion  agree  with  the  radioscopic  out- 
lines (Fig.  48).  The  contour  of  the  left  side  and  the  posi- 
tion of  the  apex  with  their  precise  form  and  location  are 
shown.  The  smallness  of  the  cardiac  area  on  this  same 
tracing  corresponds  to  the  underdevelopment  of  the 
organ,  proved  by  precise  radioscopy. 

In  simple  mitral  stenosis,  therefore,  the  left  ventricle 
is  small,  which  agrees  with  the  anatomical  findings  and 
clinical  examinations  made  by  Briquet,  Merklen  and  by 
Potain  and  Rendu. 

On  this  point  clinicians  are  not  all  agreed  and  contend 
that  in  simple  mitral  stenosis  the  heart  is  increased  in 


VALVULAR  AFFECTIONS 


81 


volume.  The  argument  advanced  for  this  is  that  the  apex 
is  lowered  and  that  its  pulsations  occur  in  the  lower  part 
of  the  fifth  space,  and  even  lower.  This  sometimes  occurs, 
but  is  not  conclusive  evidence,  and  to  judge  the  enlarge- 
ment of  the  heart  it  is  necessary  to  measure  exactly  the 
area  of  dullness.  The  area  of  dullness  is  not  diminished, 
as  is  shown  by  the  percussion  and  radiological  outlines. 
The  apex  is  displaced  because,  as  has  been  said,  the  heart 
is  lowered  as  a  whole,  and  it  is  radiology  that  demon- 
strates this. 

Radioscopy  is  superior  to  percussion  in  determining 
the  development  of  the  right  side  of  the  heart.  Percus- 
sion gives  only  approximate  information.  Radioscopy  is 
more  precise,  showing  early  a  notable  increase  in  size  of 
the  right  cavities,  while  there  are  no  symptoms,  and  com- 
pensation appears  perfect.  The  numerous  tracings  that 
we  have  been  taking  and  which  are  easy  to  interpret  have 
given  confidence.  In  mitral  stenosis,  the  heart  is  lowered 
and  at  the  same  time  undergoes  a  displacement  from  right 
to  left,  from  behind  forward,  so  that  the  right  cavities 
are  slightly  raised  towards  the  sternum.  Examination 
of  the  projected  images  indicates  this  with  certainty.  In 
these  conditions,  the  right  curve  of  the  heart  must  neces- 


FiG.  48.     SIMPLE  MITEAL  STENOSIS 
Black  lines,  orthodiagram;  dotted  lines,  percussion. 


82       THE  HEART  AND  THE  AORTA 

sarily  be  raised  in  the  upper  part  to  the  level  of  the  large 
vessels,  as  well  as  in  the  diaphragmatic  portion,  .and 
shows  an  exaggerated  development  outside  the  sternum. 

Thus  in  mitral  stenosis  the  heart  undergoes  a  slight 
double  displacement ;  a  movement  downward  which  forces 
the  apex  below  the  normal  position  and  a  seesaw  move- 
ment which  pushes  the  right  auricle  toward  the  right, 
without  a  real  enlargement  of  that  cavity. 

EXAMINATION  IN  OBLIQUE  POSITIONS 

Enlargement  of  the  left  auricle  constitutes  one  of  the 
principal  changes  in  mitral  stenosis.  There  is  great  inter- 
est in  recognizing  the  existence  and  the  degree  of  it.  The 
method  used  up  to  the  last  few  years  was  that  of  dorsal 
percussion  suggested  by  Germe  (Arras),  which  consists 
in  percussing  the  area  between  the  scapulae  and  the  verte- 
bral column,  between  the  fifth  and  tenth  dorsal  vertebras 
and  the  left  auricle.  The  zone  of  dullness  thus  outlined 
is  limited  in  the  normal  but  increases  in  marked  degree 
when  it  is  hypertrophied  or  dilated.  But  this  method 
requires  skill,  and  though  the  auricle  is  hypertrophied,  it 
may  not  be  near  enough  to  the  thoracic  wall  to  give  an 
appreciable  change  on  percussion. 

Radioscopic  examination  is  preferable.  Santiard16  has 
reported  a  case  of  mitral  stenosis  in  which  posterior  per- 
cussion did  not  show  an  enlargement  of  the  left  auricle. 
He  states,  however,  that  as  shown  by  two  radioscopic 
tracings  outlined  on  the  left  of  the  heart,  on  the  anterior 
image,  a  shadow  was  seen  certainly  produced  by  the 
dilated  left  auricle.  On  the  posterior  tracings,  the  hyper- 
trophied auricle  outlined  above  the  ventricle  is  clearly 
visible. 

Galli,17  in  1908,  published  a  tracing  of  mitral  stenosis 

is  P.  Santiard,  fflude  de  I  'aire  de  projection  du  coeur  sur  la  paroi  tho- 
racique  par  la  radiographic     These  de  Paris,  1900,  p.  57. 

17  G.  Galli,  L'orthodiagraphia  nella  diagnosi  delle  malatti  di  cuore. 
(Policlinico,  partie  med.,  1908,  XV,  2.) 


VALVULAR  AFFECTIONS  83 

which  shows  a  salient  surmounting  of  the  left  ventricle, 
attributed  to  the  projection  of  the  enlarged  left  auricle, 
as  the  pulsations  were  clearly  presystolic. 

These  examinations  were  made  in  direct  position  and 
do  not  solve  the  problem.  The  salience  which  was  noted 
between  the  arch  of  the  aorta  and  the  origin  of  the  left 
ventricle,  that  is,  at  the  level  of  the  median  arc,  corre- 
sponds not  to  the  auricle  but  to  the  auricular  appendage. 
The  auricular  salience  is  due  in  part  to  the  fact  that  the 
auricular  appendage  is  compressed  by  the  hypertrophied 
auricle,  in  part  to  the  lowering  of  the  heart  which  puts  a 
tension  on  the  vessels,  making  the  outline  of  the  pulmo- 
nary artery  more  rectilinear,  and  finally  to  the  underde- 
velopment of  the  left  ventricle  which  makes  the  projection 
of  the  pulmonary  artery  and  left  ventricle  more  appar- 
ent. It  is  not  surprising,  therefore,  that  examination  in 
the  frontal  position  brings  out  the  points  mentioned  by 
these  investigators,  which  are,  however,  only  indirect 
signs  and  more  common  in  mitral  stenosis. 

The  modifications  found  in  the  right  posterior  and  the 
left  anterior  oblique  positions  are  more  important  as  they 
allow  the  contour  of  the  left  auricle  to  be  marked  more 
precisely  towards  the  lower  third  of  the  retro-cardiac 
clear  space.  When  it  is  hypertrophied  or  dilated,  its  out- 
line is  modified ;  it  makes  a  greater  salience  than  normally 
in  the  retro-cardiac  area,  its  curve  increases,  approaches 
the  shadow  of  the  vertebral  column  and  may  even  merge 
into  it,  the  clear  space  ceasing  to  be  visible  at  the  level  of 
the  auricle. 

To  estimate  exactly  the  importance  of  the  development 
of  the  auricular  shadow  it  is  necessary  to  know  the  de- 
gree of  obliquity  of  the  body  during  the  examination.  In 
fact,  according  as  the  bi-scapular  axis  describes  with  the 
plane  of  the  screen  an  angle  of  45,  50  or  60  degrees,  the 
retro-cardiac  clear  space  is  naturally  larger  and  larger, 
and  the  outlines  of  the  heart  further  from  the  vertebral 
column,  so  that  in  the  first  place  an  examination  should  be 


84 


THE  HEART  AND  THE  AORTA 


made  at  50  degrees.  If  at  this  angle  the  clear  space  is 
obscured,  it  may  be  concluded  that  the  left  auricle  is  en- 
larged; that  it  is  considerably  enlarged  if  the  retro- 
cardiac  clear  area  does  not  appear  at  an  angle  of  inci- 
dence of  60  degrees.  But  in  order  that  the  examination 
should  be  conclusive,  the  pulmonary  spaces  should  neces- 
sarily be  transparent,  which  is  not  always  the  case  in 
patients  with  mitral  stenosis ;  it  is  necessary  also  that -the 
region  should  not  be  obscured  by  pathological  glandular 
or  pulmonary  shadows,  by  a  tumor,  or  in  the  case  of  a 
woman,  by  large  breasts. 

Care  should  be  taken  that  the  patient  raises  his  arms, 
and  breathes  deeply,  and,  in  short,  that  the  best  possible 
conditions  for  the  demonstration  of  the  auricle  be  pro- 
cured. If  necessary,  the  examination  should  be  made 
several  times,  the  patient  being  moved  until  the  best  posi- 
tion is  found  and  the  angle  of  incidence  of  the  body  noted 
each  time.  Except  in  special  circumstances,  previously 
mentioned,  the  shadow  of  the  auricle  is  finally  always 
sharply  outlined  in  the  retro-cardiac  clear  space,  and  has 
only  to  be  traced  quickly  at  the  moment  when  it  is  visible. 


Fig.  49.    EIGHT  POSTEEIOE  OBLIQUE  POSITION,  50  DEGEEES 

A,    aorta;    OG,   left   auricle;    VG,   left   ventricle;    Diaphr.,    diaphragm; 
Col.,  vertebral  column. 


VALVULAR  AFFECTIONS 


85 


The  indications  given  by  examination  in  the  oblique 
position  complete  the  radiological  diagnosis  of  simple 
mitral  stenosis. 


Fig.  50 


Fig.  51 


Fig.  50.     SAME  CASE  AS  FIG.  45.    EIGHT  POSTERIOE  POSITION, 

50  DEGREES 

Fig.  51.     SAME  CASE  AS  THE  PRECEDING,  IN  LEFT  POSTERIOR 

OBLIQUE,  50  DEGREES 

Fig.  49  shows  the  same  patient  as  Fig.  43,  which  gives 
the  details  of  examination  in  the  frontal  position.  It  will 
be  seen  there  that  the  greatly  enlarged  left  auricle  ob- 
scures with  its  shadow  all  the  middle  third  of  the  clear 
space.  In  the  lower  part  of  this  figure,  the  transparent 
triangle  is  found  included  between  the  lightly  developed 
outline  (VG-),  the  vertebral  column  (Col.)  and  the  dia- 
phragm (Diaphr.).  Above  on  the  level  of  the  aortic  prom- 
inence (A),  the  clear  space  is  readily  distinguishable, 
but  it  soon  ceases  to  be  visible  and  the  contour  of  the 
auricle  joins  the  vertebral  column. 

The  examination  of  Fig.  50  leads  to  the  same  conclu- 
sions. This  figure  is  of  a  patient  whose  cardiogram  in 
frontal  position  has  been  given  in  Fig.  45.  Here  the  left 
auricle  is  still  very  large,  as  is  shown  in  the  tracings  taken 
in  the  right  posterior  oblique  and  the  left  anterior  oblique 
positions  (Figs.  50  and  51). 


86       THE  HEART  AND  THE  AORTA 

Moreover,  percussion  showed  enlargement  of  the  auri- 
cle. 

In  Fig.  52  these  points  are  less  marked.  The  left  auri- 
cle, it  is  true,  is  very  much  increased  in  size,  since  it  forms 
a  visible  salient  in  the  retro-cardiac  space.  However,  its 
development  is  not  as  considerable  as  in  the  previous 
cases,  for  at  50  degrees  there  still  exists  a  narrow,  clear 
band  between  the  shadow  of  the  heart  and  that  of  the 
vertebral  column. 

Not  all  the  tracings  are  as  typical,  and  it  will  be  under- 
stood that  a  moderate  hypertrophy  of  the  auricle  does  not 
cause  the  same  deformations.  However,  to  be  convinced 
that  the  auricle  is  not  normal,  we  have  only  to  examine 
attentively  the  configuration  of  the  curve  which  extends 
behind  the  origin  of  the  blood-vessels,  at  the  level  of  the 
diaphragm.  It  is  seen  that  (Fig.  53)  the  highest  point  of 
this  curve,  instead  of  being  at  the  level  of  the  ventricle, 
corresponds  to  the  level  of  the  auricle ;  that  is  conclusive 
evidence  that  the  auricle  is  increased  in  volume. 

To  sum  up,  every  patient  examined  in  the  oblique  posi- 
tion at  50  degrees  who  shows  the  shadow  of  the  heart 
completely  obscuring  the  retro-cardiac  clear  space  at  the 
height  of  its  middle  third,  must  be  considered  as  having  a 


Fig.  52.  SIMPLE  MITEAL  STENOSIS.  EIGHT  POSTEEIOE  OBLIQUE 
POSITION,  50  DEGEEES.  LESS  ACCENTUATED  ENLAEGE- 
MENT  OF  THE  LEFT  AUEICLE 


VALVULAR  AFFECTIONS  87 

considerable  hypertrophy  of  the  left  auricle.  The  degree 
of  hypertrophy  is  measured  by  the  extent  of  the  reduction 
of  the  retro-cardiac  clear  space,  a  slight  reduction  corre- 
sponding to  a  moderate  increase  in  the  volume  of  the 
auricle,  provided,  of  course,  that  the  obscuring  of  the 
posterior  mediastinum  is  not  due  to  another  cause. 


Fig.   53.     BIGHT    POSTEEIOE   OBLIQUE    POSITION,    50   DEGBEES. 
MODEEATE  DILATATION  OF  THE  LEFT  AUEICLE 

MITRAL  INSUFFICIENCY 

The  clinical  history  of  mitral  insufficiency  presents 
problems,  the  solution  of  two  of  which,  at  least,  is  not 
easy.  The  first  is  whether  the  systolic  murmur  heard  at 
the  apex  belongs  simply  to  the  category  of  anorganic 
murmurs  (Potain) ;  the  second  is  to  recognize  the  cause  of 
it,  as  the  murmur  may  be  symptomatic  of  a  valvular 
lesion  or  of  functional  insufficiency.  In  this  respect  the 
indications  furnished  by  semeiology  are  often  uncertain 
and  radiological  examination  may  be  of  very  great  assist- 
ance. 

The  radiograms  of  a  typical  case  of  mitral  insufficiency 
of  rheumatic  origin  which  has  not  given  rise  to  marked 
circulatory  disturbances  will  be  studied  first.  This  case 
is  a  patient  twenty-five  years  of  age,  with  a  loud  murmur 
heard  at  the  apex  of  the  heart  during  the  whole  systole 


88 


THE  HEART  AND  THE  AORTA 


and  transmitted  toward  the  axilla.    The  affection  began 
in  adolescence  (Fig.  54). 


Fig.  54.     MITEAL  INSUFFICIENCY  WITH  COMPENSATION. 
25   YEARS   OF   AGE 


MAN 


The  form  of  the  area  of  projection  somewhat  resembles 
that  of  a  normal  horizontal  heart,  resting  on  the  dia- 
phragm. Its  development,  however,  is  clearly  exagger- 
ated on  the  right.  Moreover,  on  the  screen,  pulsations 
could  be  seen  in  the  vicinity  of  the  diaphragmatic  shadow 
(at  the  level  of  the  arrow),  which  could  only  be  caused 
by  the  right  ventricle. 

The  contour  of  the  left  ventricle  appears  normal,  its 
left  point  not  elevated.  The  apex  lies  at  the  level  of  the 
left  diaphragmatic  shadow ;  it  is  not  lowered,  but  pushed 
outward  and  rather  pointed. 

The  changes  seem  to  affect  only  the  right  heart  area 
and  this  is  confirmed  by  the  measurement  of  the  diame- 
ters :  longitudinal  diameter,  14  cm. ;  horizontal  diameter, 
14.5  cm. 

The  longitudinal  diameter  does  not  exceed  the  normal 
for  a  man  twenty-five  years  of  age,  of  average  weight,  but 
the  horizontal  diameter  is  5  mm.  greater  than  the  longi- 
tudinal: this  difference  confirms  the  radiological  diag- 
nosis, which  is  a  transverse  enlargement  of  the  heart  due 
to  the  development  of  the  right  cavities. 


VALVULAR  AFFECTIONS 


89 


In  the  right  posterior  oblique  position,  moreover,  the 
apex  of  the  heart  disappeared  behind  the  shadow  of  the 
vertebral  column  only  at  an  angle  of  42  degrees  instead 
of  at  25  to  30,  the  normal  figure.  That  could  be  explained 
only  by  a  ventricular  enlargement  in  which  the  left  ven- 
tricle was  involved  to  a  certain  extent  but  less  than  the 
right. 

Finally,  in  the  oblique  position  the  left  auricle  did  not 
appear  to  be  changed. 

These  signs  agree  with  the  pathological  findings  which 
show  that  in  mitral  insufficiency  a  slight  hypertrophy  of 
the  left  ventricle  exists,  an  insignificant  enlargement  of 
the  right  ventricle  which  varies  with  the  severity  of  the 
symptoms.  It  is  not  surprising,  therefore,  that  the  ven- 
tricles are  accentuated  when  mitral  insufficiency  is  com- 
plicated with  dyspnoea,  cyanosis,  oedema  of  the  extremi- 
ties, etc.    (See  Fig.  55.) 


Fig.  55.     MITEAL  INSUFFICIENCY.     MAEKED  ENLAEGEMENT  OF 
THE  EIGHT  HEAET.    MAN  34  YEAES  OF  AGE 


This  shows  that  the  heart  is  greatly  enlarged  and  that 
the  enlargement  is  of  the  two  ventricles,  principally  the 
right.     On  the  left,  the  ventricle  bulges,  its  contour  is 


90 


THE  HEART  AND  THE  AORTA 


elongated,  its  apex  pushed  out  but  not  lowered  and  on  the 
other  side  the  salience  of  the  shadow  corresponds  to  the 
lower  part  of  the  contour  or  to  the  region  of  the  right 
ventricle,  and  further  evidence  is  the  presence  at  this 
point  of  systolic  pulsations.  The  two  diameters  measure : 
horizontal,  19.2  cm. ;  longitudinal,  17.3  cm.,  instead  of  14. 
Both,  then,  have  increased,  especially  the  horizontal, 
which  denotes  a  generalized  hypertrophy,  but  predomi- 
nant on  the  right. 


Fig.  56.     MITEAL  INSUFFICIENCY.    ASYSTOLIC  PERIOD 


Fig.  56  shows  a  patient  with  confirmed  asystolic 
changes  in  which  these  characteristics  are  still  more 
accentuated.  The  transverse  enlargement  of  the  heart  is 
considerable ;  it  is  very  much  lowered  on  the  right  where 
its  greatly  elongated  contour  deviates  progressively  from 
the  median  line  to  the  level  of  the  diaphragm.  The  apex 
is  elevated  and  pushed  to  the  left,  toward  the  thoracic 
wall.  Both  diameters  are  increased  and  the  horizontal  is 
much  greater  than  the  longitudinal.  On  the  screen  pulsa- 
tions were  seen  to  be  very  feeble,  especially  in  the  right 
ventricular  area. 


VALVULAR  AFFECTIONS 


91 


In  these  cases,  radiological  examination  only  confirms 
an  evident  diagnosis.  There  are  other  cases  in  which  the 
clinical  signs  were  less  clear  and  in  which  radiological 
examination  nevertheless  gave  the  same  results. 

Orthodiagram  57  is  of  a  woman  who  had  an  apical  sys- 
tolic murmur  but  who  showed  no  functional  trouble  that 
would  indicate  a  cardiac  lesion. 

By  fluoroscopic  examination  there  seemed  to  be  no 
notable  modifications.  The  diameters  measured:  hori- 
zontal, 10.5  cm. ;  longitudinal,  11.2  cm.,  about  the  normal 


Fig.   57.      SLIGHT   MITEAL   INSUFFICIENCY.      WOMAN  32   YEAKS 

OF  AGE 


figures.  However,  the  right  outline  was  slightly  exag- 
gerated, and  in  deep  inspiration  the  inferior  contour  of 
the  heart  clearly  projected  over  the  diaphragm,  which 
could  be  explained  only  by  an  enlargement  of  the  right 
ventricle.  Moreover,  by  goniometer  readings,  the  apex 
disappeared  behind  the  shadow  of  the  vertebral  column 
only  at  an  angle  of  40  degrees.  The  heart,  therefore,  was 
pathological,  and  the  changes  found,  such  as  an  increase 


92       THE  HEART  AND  THE  AORTA 

of  the  right  contour,  lowering  of  the  inferior  margin  of 
the  corresponding  ventricle,  disappearance  of  the  apex 
at  too  great  an  angle  of  incidence,  proved  that  a  moderate 
but  indisputable  enlargement  of  the  heart,  especially  of 
the  right  ventricle,  existed,  indicating  mitral  insufficiency. 

These  proofs  are  of  practical  importance  in  relation  to 
differential  diagnosis  of  systolic  murmurs  of  the  apex, 
which  is  at  times  difficult.  Frequently  these  kinds  of 
murmurs  are  of  anorganic  nature  and  their  characteris- 
tics are  not  always  clear  enough  to  distinguish  them. 
They  occur  less  frequently  than  as  stated  by  Potain  for 
the  reason  that  functional  murmurs  were  not  included. 
If  a  mitral  lesion,  however  well  compensated,  were  always 
accompanied  by  changes  visible  on  the  radioscopic  screen, 
the  question  would  be  settled.  This  is  not  absolutely  so, 
but  nevertheless  radiological  examination  does  give  valu- 
able information  in  this  respect.  It  may  be  considered 
in  the  following  manner : 

Any  patient  who  by  radiological  examination  shows  no 
abnormal  heart  changes,  no  increase  in  the  volume  of  the 
ventricular  cavities,  must  be  regarded  as  free  from 
lesions  of  insufficiency,  irrespective  of  the  results  of  clini- 
cal examination.  On  the  other  hand,  any  patient  in  whom 
auscultation  reveals  the  existence  of  a  murmur,  the  nature 
and  position  of  which  would  tend  to  put  it  in  the  category 
of  anorganic  sounds,  should  be  suspected  of  mitral  insuffi- 
ciency, if  radiological  examination  demonstrates  all  or 
part  of  the  changes  previously  described. 

The  accuracy  of  these  statements  has  often  been  veri- 
fied. In  individuals  with  a  superficial  anorganic  murmur, 
constantly  varying  with  change  of  position,  radiological 
examination  has  not  shown  any  heart  changes,  and  when 
the  murmur  did  not  present  these  characteristics,  investi- 
gation, at  first  not  convincing,  finally  showed  a  slow  but 
progressive  enlargement  of  the  volume  of  the  heart  which 
enabled  a  diagnosis  to  be  made  which  had  previously 
been  questionable. 


VALVULAR  AFFECTIONS  93 

FUNCTIONAL  MITRAL  INSUFFICIENCY. 

Another  interesting  question  is  to  determine  the  nature 
of  a  mitral  insufficiency  which  has  been  recognized  by  the 
usual  clinical  signs  and  by  radiological  examination. 

Mitral  insufficiency  does  not  always  have  the  same 
origin.  It  results  either  from  an  endocarditis,  or  from  a 
sudden  or  slow  dilatation  of  the  left  ventricle ;  in  this  case 
it  may  disappear  under  the  influence  of  appropriate  care 
and  treatment,  or  may  continue  indefinitely.  This  latter 
type  of  insufficiency  is  called  functional.  Its  diagnosis, 
often  difficult,  depends  on  anamnesis,  the  habitual  but  not 
constant  presence  of  an  arterial  hypertension  or  gallop- 
ing sound,  and  especially  on  the  percussion  and  palpa- 
tion findings  which  reveal  a  considerable  increase  of  the 
left  ventricle.  These  signs,  however,  are  not  always  con- 
clusive, and  radioscopic  examination  is  then  of  great 
assistance.    Here  is  an  example : 

A  patient  forty-six  years  of  age,  subject  for  two  years 
to  dyspnoea  on  exertion,  had  been  in  the  hospital  in  1908 
and  in  January,  1910,  for  suffocating  attacks  of  an  oedem- 
atous  nature.  In  March,  1910,  he  entered  our  depart- 
ment, with  a  similar  attack  which  yielded  to  a  copious 
phlebotomy.  Examination  showed  that  the  heart  was 
enlarged  and  dilated,  and  that  at  the  apex  there  was, 
together  with  a  very  clear  purring  thrill,  a  somewhat 
modified  systolic  murmur,  superficial,  rather  rough  and 
lying  below  and  within  the  heart  apex.  Arterial  pressure 
was  15  cm.  by  sphygmometer.  The  urine  contained  a 
considerable  quantity  of  albumen. 

The  logical  diagnosis  from  these  findings  should  be  as 
follows :  mitral  insufficiency  with  beginning  cardiac  insuf- 
ficiency. The  principal  points  of  the  case,  notably  the 
pulmonary  cedematous  attacks  and  the  absence  of  periph- 
eral oedema,  are  not  explained.  Finally,  no  history  of 
infectious  disease  was  found  which  could  have  given  rise 
to  mitral  endocarditis. 


94 


THE  HEART  AND  THE  AORTA 


Radioscopic  examination  gave,  on  the  other  hand,  vain- 
able  information  (Fig.  58). 


Fig.  58. 


FUNCTIONAL  MITEAL  INSUFFICIENCY. 
OF  AGE 


MAN  46  YEAES 


It  enabled  recognition  at  once  of  the  ordinary  signs  of 
mitral  insufficiency:  apex  slightly  lowered  bnt  pushed 
outward,  with  enlargement  of  the  right  ventricle;  it 
showed,  moreover,  certain  anomalies.  The  contour  of  the 
left  ventricle  was  more  marked  than  in  cases  of  endocar- 
ditic  mitral  insufficiency;  the  apex,  instead  of  being 
pointed,  was  rounded,  slightly  globulous.  Finally,  the 
longitudinal  diameter  measured  16.8  cm.,  while  the  hori- 
zontal was  only  16.3  cm.,  so  that  there  was  a  difference  in 
favor  of  the  longitudinal  diameter  contrary  to  what  we 
have  indicated  in  the  foregoing.18 

In  conclusion,  in  estimating  the  total  increase  in  the 
volume  of  the  heart,  hypertrophy  of  the  left  ventricle 
played  a  much  greater  part  than  in  the  case  of  simple 
mitral  insufficiency. 

The   impression    derived    from   clinical    examination, 

is  In  analogous  cases  the  figure  of  the  index  of  depth  is  singularly  in- 
structive; it  rises  to  20,  25  centimeters  and  even  more,  which  indicates 
marked  enlargement  of  the  left  ventricle. 


VALVULAR  AFFECTIONS 


95 


namely,  that  it  was  a  mitral  insufficiency  of  functional 
origin,  was  therefore  confirmed. 

The  evolution  of  symptoms  soon  showed  that  this  was 
correct.  After  some  days  of  rest,  the  patient  having  been 
placed  on  a  milk  diet  and  treated  with  digitalis,  the  dis- 
turbances steadily  diminished.  The  murmur  at  the  apex 
disappeared  and  was  replaced  by  a  galloping  rhythm  in 
the  left  preventricular  region. 

It  was  not  a  cardiac  but  a  cardio-renal  case  and  this 
conclusion  was  due  to  radiological  examination.  The 
diagnosis  could  therefore  be  made :  cardiac  hypertrophy, 
dilation  of  the  left  heart,  functional  mitral  insufficiency  in 
a  patient  with  renal  sclerosis. 

The  case  shown  in  the  following  tracing  (Fig.  59)  gave 
rise  to  the  same  problem  which  was  solved  in  the  same 
way.  The  patient  was  a  man  fifty-three  years  of  age  with 
mitral  insufficiency  due  in  the  absence  of  previous  infec- 
tions to  a  generalized  alteration  of  the  arterial  system. 


Fig.   59.     MITEAL   INSUFFICIENCY   AND   AETEEIAL    SCLEEOSIS. 
MAN  53  YEAES  OF  AGE 


Eadioscopic  examination  showed  a  considerable  en- 
largement of  the  left  heart,  the  apex  was  lowered  and 
rounded,  the  right  ventricle  bulged  a  good  deal  to  the 


96       THE  HEART  AND  THE  AORTA 

right,  the  diameters  measured :  horizontal,  15.2  cm. ;  lon- 
gitudinal, 16.6  cm. — a  deviation  the  inverse  of  what  is 
seen  in  endocarditic  mitral  insufficiency.  The  aorta, 
moreover,  was  very  much  dilated,  its  walls  were  dense, 
and  pulsations  feeble.  These  findings  proved  that  the 
patient  was  affected  with  cardio-vascular  sclerosis  and 
that  mitral  insufficiency  was  only  a  secondary  symptom 
developed  in  the  course  of  his  affection. 

MITRAL  DISEASE 

There  are  cases  in  which  the  radiological  tracing  is 
sufficiently  characteristic  in  itself  to  justify  the  suspicion 
of  a  lesion  apart  from  the  clinical  examination  of  the 
patient.    The  following  is  an  example : 

A  young  woman  was  seen  by  one  of  us  at  the  request 
of  a  colleague  who  had  previously  made  an  orthodia- 
graphic  examination  of  the  patient's  heart.  The  whole 
pathological  history  was  clearly  presented.  The  heart 
and  the  auricle  showed  deformations  which  could  be  ex- 
plained only  by  a  double  mitral  lesion.  Moreover,  the 
very  visible  increase  of  the  contour  of  the  right  ventricle 
presupposed  the  existence  of  marked  failure  of  compen- 
sation, so  that  before  we  saw  the  patient  the  follow- 
ing diagnosis  was  justified:  mitral  stenosis  complicated 
with  insufficiency,  together  with  cardiac  insufficiency — 
which  clinical  examination  confirmed. 

This  method  of  procedure  is  not  difficult  and  with  little 
experience  the  interpretation  of  orthodiagraph^  tracings 
can  be  made.    Fig.  60  illustrates  this. 

It  is  seen  here  that  in  the  frontal  position  the  point  G 
is  surmounted  by  a  salience  and  that  the  right  contour 
shows  an  unusual  development.  These  are  characteristics 
peculiar  to  mitral  stenosis.  In  the  oblique  position,  it  is 
necessary  to  put  the  patient  at  an  angle  of  60  degrees 
in  order  that  the  retro-cardiac  clear  space  should  appear 
as  a  narrow  band  in  which  a  shadow  is  seen,  due  to  the 


VALVULAR  AFFECTIONS 


97 


hypertrophy  of  the  left  auricle  (Fig.  61).    These  are  the 
particular  characteristics  of  mitral  stenosis. 

In  direct  position,  the  apex,  moreover,  is  not  sharp  as 
in  simple  mitral  stenosis ;  it  is  rather  rounded  and  is  de- 
pressed below  the  diaphragm  and  during  deep  inspiration 
the  inferior  contour  of  the  heart  is  below  the  diaphrag- 
matic shadow.  Finally,  in  determining  at  what  angle  the 
apex  of  the  heart  disappears  behind  the  shadow  of  the 


Fig.  60 
Fig.  60.     DOUBLE  MITEAL  LESION. 


Fig.  61 
GIRL  11  YEAES  OF  AGE 


Fig.  61.  SAME  PATIENT.  DOUBLE  SALIENCE  OF  LEFT  AURICLE 
AND  OF  LEFT  VENTEICLE  IN  EIGHT  POSTEEIOE  OBLIQUE 
POSITION,  60  DEGEEES 

vertebral  column,  it  is  found  to  be  45  degrees,  a  high 
figure  and  indicating  that  the  left  ventricle  is  enlarged. 
A  further  proof  of  this  is  that  in  left  posterior  oblique 
position  at  60  degrees  the  ventricle  projects  below  the  left 
auricle  in  the  retro-cardiac  clear  space. 

In  this  tracing,  changes  are  found  which  belong  on  the 
one  hand  to  mitral  stenosis  and  on  the  other  to  insuffi- 
ciency. This  diagnosis  was  further  confirmed  by  the 
clinical  findings,  as  the  patient  had  a  purring  thrill  at  the 
apex,  a  diastolic  rumble  and  a  presystolic  and  systolic 
murmur. 

The  increase  in  the  volume  of  the  left  auricle  and  the 
hypertrophy  of  the   left  ventricle,   which  with   double 


98 


THE  HEART  AND  THE  AORTA 


mitral  lesions  give  special  radioscopic  findings,  are  seen 
in  all  cases  of  mitral  disease.    Figs.  62  and  63,  a  patient 


Fig.  62 


Fig.  63 


Fig.  62.     DOUBLE  MITEAL  LESION  IN  THE  ACUTE  STAGE. 
20.YEAES  OF  AGE 


MAN 


Fig.  63.     SAME  PATIENT,  IN  EIGHT  POSTEEIOE  OBLIQUE 
POSITION,  40  DEGEEES 

with  double  mitral  lesion  in  the  acute  stage,  can  be  inter- 
preted in  the  same  manner. 

In  the  frontal  position  (Fig.  62),  a  salience  of  the  left 
median  arc  and  a  notable  enlargement  of  the  left  ventricle 
are  seen ;  the  diameters  of  the  heart  are  exaggerated,  the 
longitudinal  measures  15.2  cm.,  and  the  horizontal,  15.7 
cm.  In  right  posterior  oblique  position  (Fig.  63),  the 
retro-cardiac  clear  space  is  completely  obscured  by  the 
left  auricle  and  the  left  ventricle  shadows. 

These  characteristics  are  somewhat  modified  when  the 
cardiac  lesion  is  complicated  by  asystolic  phenomena; 
the  right  ventricle  then  plays  a  more  and  more  important 
part  in  the  enlargement  of  the  heart,  its  lower  contour 
makes  a  salient  which  is  greater  according  as  there  is 
more  hypertrophy  or  dilatation  of  the  ventricle,  while 


VALVULAR  AFFECTIONS 


99 


the  apex  of  the  heart  is  pushed  outward.  The  index  of 
depth  shows  in  a  clearer  manner  the  degree  of  posterior 
development  of  the  heart.  Examinations  in  the  oblique 
position  confirmed  these  findings. 

But  what  is  more,  sometimes  radioscopic  examination 
determines  the  respective  part  played  by  stenosis  and 
insufficiency  in  the  case  of  a  double  mitral  lesion. 

Fig.  64  shows  a  girl  eight  years  old  in  whom  ausculta- 
tion gave  all  the  signs  of  a  similar  affection,  and  it  shows 
what  clinical  examinations  could  not  discover,  that  mitral 
stenosis  had  much  more  to  do  with  the  case  than  insuffi- 
ciency. 

In  the  frontal  position,  the  median  arc  is  much  exag- 
gerated. Point  D  is  elevated;  the  upper  portion  of  the 
right  contour  is  abnormally  developed.  Here  are  all  the 
signs  of  a  marked  dilatation  of  the  left  auricle."  On  the 
other  hand,  the  left  ventricle  is  moderately  enlarged,  for 
if  the  apex  does  not  separate  from  the  diaphragm  during 
deep  inspiration,  it  disappears  in  the  right  posterior 
oblique  position  behind  the  vertebral  column  only  at  a 
slightly  greater  angle  than  normal. 

In  the  right  posterior  oblique  position  at  50  degrees 
(Fig.  65),  the  auricle  is  very  large  and  completely  ob- 


Fig.  64 


Fig.  65 


Fig.  64.     DOUBLE  MITEAL  LESION  WITH  MITEAL  STENOSIS 
PEEDOMINANT.     GIEL  8  YEARS  OF  AGE 

Fig.  65.    SAME  CASE,  IN  EIGHT  POSTEEIOE  OBLIQUE,  50  DEGEEES 


100 


THE  HEART  AND  THE  AORTA 


scures  the  retro-cardiac  clear  space.  The  shadow  of  the 
left  auricle  is  not  large,  for  the  lower  part  of  the  retro- 
sternal space  is  visible  as  a  small  transparent  triangular 
zone.  The  conclusion  is  decisive,  and  if  there  is  a  double 
mitral  lesion,  stenosis  is  more  marked  here  than  insuffi- 
ciency. 

Radiological  examination  has  allowed  the  objectifying 
of  deformations  of  the  heart  due  to  the  regular  evolution 
of  a  mitral  lesion,  and  also  those  which  are  the  result  of 
superadded  complications.  These  may  have  various 
origins. 


Fig.  66.     PULMONAEY  INSUFFICIENCY  COMPLICATING  MITEAL 

DISEASE 
Exaggeration  of  the  pulmonary  arc.     Heart  ' '  en  sabot. ' ' 

They  result  either  from  mechanical  disturbances  or 
from  the  secondary  localization  of  infectious  processes 
at  the  site  of  the  regions  previously  affected. 

Stell  in  1886,  and  again  in  1906,  called  attention  to  the 
curious  fact,  that  mitral  lesions,  especially  stenosis,  could 
provoke,  following  increase  of  pressure  in  the  smaller 
vessels,  an  insufficiency  of  the  pulmonary  orifice  of  func- 
tional nature,  demonstrated  by  a  soft  diastolic  murmur, 
heard  along  the  left  border  of  the  sternum.    Since  then 


VALVULAR  AFFECTIONS  101 

further  cases  have  been  reported  and  we  have  also  ex- 
amined a  certain  number.  This  association  adds  a  diffi- 
culty to  the  diagnosis,  since  the  diastolic  murmur  may 
reasonably  be  considered  symptomatic  of  an  aortic  lesion. 
Radioscopic  examination,  however,  removes  all  doubt 
respecting  diagnosis.    Fig.  66  demonstrates  this. 

The  case  is  that  of  a  woman  with  a  double  mitral  lesion, 
stenosis  being  predominant  over  insufficiency.  This  pa- 
tient had  had  several  attacks  of  severe  dyspnoea  which 
were  later  less  severe  when  a  new  sign  appeared,  a  dias- 
tolic murmur  with  the  characteristics  previously  indi- 
cated, undoubtedly  due  to  pulmonary  insufficiency.  The 
proof  of  it  is  furnished  by  the  orthodiagram  in  question. 
A  marked  development  of  the  pulmonary  arc  is  seen,  a  no- 
table dilatation  of  the  right  cavities  giving  the  heart  the 
appearance  of  the  "sabot"  which  is  usual  in  lesions  of 
the  right  heart.  The  configuration  bears  no  resemblance 
to  what  is  found  in  aortic  lesions. 

Pulmonary  insufficiency,  however,  may  still  be  mani- 
fested, as  Lutembacher19  has  noted,  in  the  course  of  one 
of  those  variations  of  secondary  subacute  endocarditis 
which  are  common  among  cardiacs.  In  the  case  which 
we  are  considering,  the  inflammatory  process  is  not  con- 
fined to  the  endocardium,  but  extends  to  the  pulmonary 
circulatory  system  and  gives  rise  to  a  pulmonary  endar- 
teritis with  embolism  or  thrombosis,  which  on  ausculta- 
tion is  accompanied  first  by  an  exaggeration  of  the  second 
pulmonary  sound,  then  by  a  diastolic  murmur  characteris- 
tic of  functional  insufficiency  of  the  orifice. 

On  the  radioscopic  screen,  changes  identical  with  those 
which  have  just  been  indicated  are  noted.  The  only  dif- 
ference consists  in  this,  that  they  develop  rapidly,  the 
pulmonary  arc  presenting,  at  least  in  the  course  of  a  few 
days,  a  great  exaggeration  of  its  diameters  (Fig.  67). 

As  is  readily  seen,  radioscopic  images  are  not  always 

i9E.  Lutembacher,  Endocardite  subaique  chez  les  cardiaques.  (Archives 
des  maladies  du  cceur,  des  vaisseaux  et  du  sang,  aout,  1917.) 


102      THE  HEART  AND  THE  AORTA 

the  same  in  cases  of  mitral  lesion,  bnt  their  dissimilarity 
is  due  to  the  fact  that  the  anatomical  configuration  of  the 
heart  is  modified  according  to  the  type  and  degree  of  the 
lesion.  These  images  enable  the  diagnosis  to  be  confirmed 
and,  in  a  certain  measure,  the  progress  of  the  lesion  to  be 
followed ;  but  in  order  to  be  able  to  interpret  them  prop- 
erly, it  is  necessary  to  have  at  the  same  time  a  complete 
clinical  and  radiological  knowledge. 


Fig.   67.     PULMONARY   INSUFFICIENCY   IN   THE    COURSE    OF   A 
SECONDARY  SUBACUTE  ENDOCARDITIS 
Exaggeration  of  the  pulmonary  arc.     Heart  "en  sabot." 

AORTIC  INSUFFICIENCY 

The  two  principal  types  of  insufficiency  will  be  studied : 
endocarditic  aortic  insufficiency  and  aortic  insufficiency, 
either  arterial  or  subsequent  to  changes  of  the  vessel, 
extending  to  the  semilunar  valves. 

ENDOCARDITIC     AORTIC     INSUFFICIENCY 

Fig.  68  is  of  a  patient  with  typical  aortic  insufficiency, 
of  rheumatic  origin,  with  as  yet  no  serious  failure  of 
compensation. 


VALVULAR  AFFECTIONS 


103 


It  shows  the  shadow  of  the  heart  occuj>ying  a  some- 
what median  position  and  the  apex,  which  is  lowered,  only 
slightly  pushed  outward;  moreover,  it  is  rounded  and 
is  not  separated  from  the  left  diaphragm  during  forced 
inspiration.  The  general  form  suggests  somewhat  a 
purse,  the  bottom  of  which  would  correspond  to  the  heart 
apex. 

The  contour  of  the  left  ventricle  is  elongated,  convex, 
but  not  exaggerated.  Point  Gr,  though  not  very  abnor- 
mally elevated,  lies  a  little  too  high,  being  on  the  same 
line  as  the  corresponding  point  D.  Finally,  the  whole 
length  of  the  left  outline  shows  systolic  pulsations  of 
marked  amplitude  and  force. 

The  right  contour  is  normal  and  this  contour,  more- 
over, is  not  modified  except  at  the  period  when  functional 
disturbances  appear ;  the  presence  of  systolic  pulsations, 
perceptible  rather  high  above  the  diaphragm,  does  not 
necessarily  indicate  hypertrophy  or  dilatation  of  the  ven- 
tricle to  the  right ;  it  may  simply  mean  that  the  ventricle 
is  pushed  back  as  a  result  of  the  lowering  of  the  heart 
and  its  displacement  toward  the  median  line,  because  of 
the  weight  of  the  left  ventricle. 


Fig.  68.     AOETIC  INSUFFICIENCY.     PEEIOD  OF  COMPENSATION. 
MAN  40  YEAES  OF  AGE 


104 


THE  HEART  AND  THE  AORTA 


Finally — and  this  agrees  with  the  preceding  data — the 
longitudinal  diameter  exceeds  the  normal,  and  the  hori- 
zontal diameter  is  decidedly  less. 

In  the  right  posterior  oblique  position  (Fig.  69),  the 
apex  of  the  heart  disappears  behind  the  vertebral  column 
only  at  a  wide  angle,  a  fact  which  is  easily  explained,  if 
it  is  granted,  as  has  been  shown,  that  hypertrophy  of  the 
left  ventricle  in  its  early  stage  affects  the  mediastinal 
area.  Sometimes  the  enlargement  is  so  slight  that  it  can 
be  shown  only  by  determining  index  depth. 


Fig.  69.     SAME  CASE,  IN  EIGHT  POSTEEIOE  OBLIQUE  POSITION 

At  an  angle  of  40  degrees,  the  apex  of  the  heart  has  not  yet  disappeared 
behind  the  vertebral  column. 

The  preceding  images,  therefore,  lead  to  the  conclusion 
that  the  patient  is  suffering  from  marked  hypertrophy 
of  the  left  ventricle  without  involvement  of  the  other 
cavities.  This  view  of  the  heart  is  characteristic  of 
severe  aortic  insufficiency  when  it  has  not  yet  given  rise 
to  grave  symptoms.  It  is  necessarily  completely  modi- 
fied when  it  is  caused  by  asystolic  disturbances  which 
provoke  secondary  deformations  of  the  other  cardiac 
cavities. 

The  hypertrophy  of  the  left  ventricle  is  sometimes  so 
slight  in  the  course  of  aortic  lesions  that  it  might  easily 
escape  attention  if  recourse  were  not  had  to  the  different 


Fig.   70.     TELEEADIOGEAPH  OF  AORTIC  INSUFFICIENCY 


VALVULAR  AFFECTIONS  105 

methods  indicated.  In  this  case  we  might  conclude 
that  the  heart  is  normal  and  if  clinical  signs  are  not  char- 
acteristic, admit  that  valvular  cardiopathy  does  not 
exist.    The  following  is  an  example. 

On  auscultation,  the  patient  gave  a  rather  accentuated 
diastolic  murmur  at  the  aortic  area  but  of  questionable 
character.  In  the  frontal  position  orthodiagraphic  ex- 
amination showed  no  pathological  characteristic;  the 
diameters  of  the  cardiac  shadow  were  normal;  the  apex 
was  a  little  low  and  globulous.  It  was  insufficient  to 
prove,  however,  that  the  left  ventricle  was  enlarged.  Yet 
the  index  of  depth  was  slightly  but  definitely  exaggerated. 
Finally,  in  the  right  posterior  oblique  position  it  was 
necessary  to  place  the  patient  at  an  angle  of  35  degrees 
(instead  of  30,  the  normal  figure)  to  cause  the  apex  to 
disappear.  After  that  it  was  necessary  to  revise  the 
negative  conclusions  of  the  examination  made  in  the 
frontal  position.  The  globulous  form  of  the  apex,  the 
exaggeration  of  the  angle  at  which  it  ceased  to  be  visible 
in  right  posterior  oblique  position,  the  increase  in  the 
index  of  depth,  were  sufficient  evidence  that  hypertrophy 
of  the  left  ventricle  existed,  slight,  it  is  true,  but  indis- 
putable. 

On  the  contrary,  there  are  cases  in  which  aortic  insuffi- 
ciency, however  well  compensated,  is  accompanied  by  a 
considerable  ventricular  hypertrophy  readily  perceptible 
by  the  ordinary  methods  of  radiological  examination. 
The  teleradiogram  (Fig.  70)  is  a  typical  case.  The  ap- 
pearance of  serious  functional  disturbances  only  in- 
creases ventricular  hypertrophy,  which  may  attain  ex- 
cessive dimensions,  as  shown  in  Fig.  71. 

Radiological  examination  is  able  also  to  demonstrate 
the  coexistence  with  aortic  insufficiency  of  valvular  cardi- 
opathy, notably  of  mitral  stenosis.  This  is  interesting, 
for  it  has  been  assumed,  for  purely  theoretical  reasons, 
that  the  association  of  these  two  lesions  was  a  rather 
favorable  condition.    But  in  the  great  majority  of  cases 


106      THE  HEART  AND  THE  AORTA 

the  coexistence  of  a  mitral  stenosis  with  aortic  insuffi- 
ciency has  been  based  only  on  the  presence  of  a  presys- 
tolic murmur  at  the  level  of  the  apex.  This  is  not  suffi- 
cient, and  today  we  know  that  simple  aortic  insufficiency 
is  often  accompanied  by  a  murmur  which  has  nothing  to 
do  with  mitral  stenosis  and  which  is  due  exclusively  to 
intra-ventricular  circulation  provoked  by  the  reflux  of  the 


Fig.   71.     AOETIG  INSUFFICIENCY,  ASYSTOLIC  PERIOD 

Considerable  hypertrophy  of  the  left  ventricle,   dilatation   of   the  right 
cavities. 

blood;  what  has  been  known  as  Flint's  murmur.  It  is 
not  surprising  that  aortic  insufficiency  accompanied  by 
a  murmur  should  generally  be  a  favorable  prognosis,  for 
aortic  insufficiency  alone  is  not  accompanied  by  any  other 
lesion.  On  the  other  hand,  where  there  is  a  combination 
of  aortic  insufficiency  and  mitral  stenosis,  the  prognosis 
is  always  more  serious.  In  pathology  as  in  arithmetic, 
one  and  one  make  two,  and  an  isolated  lesion  of  the  heart 
entails  less  risk  than  a  double  lesion. 

But  how  shall  it  be  determined  whether  aortic  insuffi- 
ciency is  complicated  with  mitral  stenosis,  when  the  most 


VALVULAR  AFFECTIONS 


107 


characteristic  sign  of  this  latter  affection,  the  murmur, 
is  found  in  both  cases  ?  There  is  only  one  way  of  deciding 
it :  that  is  to  determine  the  volume  of  the  left  auricle, 
which  is  always  increased  in  the  case  of  mitral  stenosis, 
and  is  normal,  contrary  to  what  Potain  and  Rendu  have 
said,  in  aortic  insufficiency  alone.  It  is  difficult  to  esti- 
mate the  volume  of  the  left  auricle  by  the  ordinary  means 
of  examination,  and  the  method  of  dorsal  percussion  em- 
ployed is  not  always  successful,  whereas  radiology  gives 
conclusive  information  (see  Fig.  72). 

Fig.  72  is  of  a  patient  who  showed  positive  signs  of 
aortic  insufficiency  and  signs  which  gave  the  impression 
without  affirming  it,  that  a  mitral  stenosis  was  also 
present.  The  view  of  the  heart  in  the  frontal  position 
recalls,  indeed,  what  is  found  in  aortic  insufficiency.  The 
left  ventricle  is  greatly  enlarged  and  the  right  contour  is 
almost  normal.  The  apex  of  the  heart  is  pushed  out  but 
not  elevated ;  it  is  rather  lowered,  rounded  and  globulous. 
To  this  should  be  added  the  fact  that  the  left  ventricle 


Fig.  72  Fig.  73 

Fig.  72.     AORTIC  INSUFFICIENCY  AND  MITRAL  STENOSIS 

Fig.    73.     SAME    CASE,   IN   RIGHT    POSTERIOR   POSITION,   AT    50 

DEGREES 


108      THE  HEART  AND  THE  AORTA 

pulsations  showed  in  the  course  of  radioscopic  examina- 
tion an  unusual  amplitude. 

On  this  same  tracing,  however,  the  median  arc  is  seen 
to  be  increased,  which  leads  to  the  supposition  that  the 
auricle  must  be  abnormally  developed. 

In  the  right  posterior  oblique  position  (Fig.  73),  this 
last  sign  becomes  clear.  It  is  seen  that  in  the  retro- 
cardiac  clear  space  is  a  shadow  due  in  part  to  the  left 
ventricle,  and  in  part  also,  in  the  upper  region,  to  the 
auricle.  For  this  to  occur,  the  auricle  itself  must  neces- 
sarily be  enlarged.  Both  examinations  then  showed  that 
there  was  indeed  a  combination  of  the  two  lesions :  aortic 
insufficiency  and  mitral  stenosis. 

AORTIC  INSUFFICIENCY  OF  ARTERIAL  ORIGIN 

In  the  preceding  cases  aortic  insufficiency  constituted, 
as  stated,  the  entire  disease,  the  aorta  presenting  no 
changes.  This  type  of  lesion,  relatively  favorable,  is  con- 
sistent with  a  more  or  less  long  life.  But  it  is  not  the 
case  with  a  valvular  lesion  when  it  coincides  with  exten- 
sive changes  in  the  vascular  system,  principally  of  the 
aorta,  and  the  prognosis  then  is  entirely  different.  It 
is  always  important  to  know  exactly  the  condition  of  the 
aorta  in  cases  of  aortic  insufficiency.  Radioscopy  fur- 
nishes in  such  cases  more  information  than  other  methods 
of  examination. 

The  orthodiagram  in  Fig.  74  is  of  a  man  fifty-three 
years  of  age,  with  a  diastolic  murmur  at  the  base  char- 
acteristic of  aortic  insufficiency.  This  lesion  did  not  cause 
much  disturbance.  The  preceding  year,  however,  follow- 
ing common  grippe,  severe  symptoms  of  cardiac  failure 
appeared  without  any  history  which  might  explain  the 
cause  of  a  valvular  lesion.  The  supposition  was  correct 
then,  that  it  must  be  of  arterial  origin,  although  palpation 
and  percussion  did  not  show  enlargement  of  the  aorta. 

Orthodiagram  74  confirms  the  diagnosis  of  aortic  in- 


VALVULAR  AFFECTIONS 


109 


sufficiency.  It  is  seen  here,  that  in  the  frontal  position 
the  left  contour  is  elongated  and  dilated,  that  the  apex 
is  rounded  and  lowered,  which  is  evidence  of  serious  ven- 
tricular hypertrophy.  Examination  of  the  aortic  out- 
line, moreover,  shows  that  the  vessel  is  dilated  at  its 


Fig.  74 


Fig. 


Fig.    74.     AOETIC   INSUFFICIENCY   WITH   DILATATION   OF    THE 
AORTA  AT  ITS  POINT  OF  ORIGIN.    MAN  53  YEARS  OF  AGE 

Fig.  75.     SAME   PATIENT   IN   RIGHT    ANTERIOR   OBLIQUE    POSI- 
TION AT  45  DEGREES.     THE  CALIBER  OF  THE  AORTA  IS  LARGER 
AT  THE  ORIGIN  THAN  AT  THE  LEVEL  OF  THE  ARCH 

origin  from  the  valvular  ring  to  the  level  of  the  arch 
where  it  resumes  its  normal  caliber.  On  the  right  it 
projects  over  the  sternum,  and  at  this  point  (at  the  level 
of  the  arrow)  the  aortic  shadow  shows  very  ample  pul- 
sations. 

In  the  right  anterior  oblique  position  (Fig,  75),  the 
aortic  shadow  assumes  the  form  of  a  cone,  the  largest 
part  of  which  corresponds  to  the  base  of  the  heart. 

The  conclusion  from  the  examination  of  these  two 
figures  is  that  there  was  aortic  insufficiency,  as  ausculta- 
tion indicated,  but  that  this  lesion  was,  so  to  speak,  only 
an  epiphenomenon  occurring  in  the  course  of  aortitis. 

In  the  following  case  (Fig.  76),  the  clinical  and  radio- 


110 


THE  HEART  AND  THE  AORTA 


scopic  signs  were  still  more  emphasized.  A  man  thirty- 
nine  years  of  age  with  Hodgson's  disease,  presenting 
serious  functional  disturbances :  dyspnoea  on  exertion, 
vertigo  and  anginose  attacks.  The  tracing  shows  in  the 
frontal  position  a  considerable  enlargement  of  the  area 
of  projection  of  the  heart.  The  longitudinal  diameter 
measures  16  cm.,  the  horizontal,  13.2  cm.;  the  apex  is 


Fig.   76.     AOETIC  INSUFFICIENCY   OF  ARTERIAL   ORIGIN.     MAN 
39  YEARS  OF  AGE 


rounded  and  lowered.  In  the  right  posterior  oblique 
position  it  disappears  behind  the  vertebral  column  only 
at  an  angle  of  48  degrees.  On  the  screen  the  left  contour 
of  the  heart,  greatly  enlarged,  showed  ample  pulsations ; 
the  ascending  portion  of  the  aorta  was  dilated,  tortuous, 
dense,  and  at  each  systole  the  arch  as  a  whole  showed 
forcible  pulsation. 

There  were  found  characteristics  of  both  lesions : 
aortitis  and  valvular  insufficiency.  But  these  lesions  were 
accompanied,  besides,  by  an  interesting  peculiarity. 
Whereas  in  cases  of  simple  aortitis  the  vascular  contour 


VALVULAR  AFFECTIONS  111 

is  muck  reduced  in  its  rhythmic  expansion,  because  of 
the  thickening  of  the  arterial  walls,  here,  on  the  contrary, 
the  arch  was  animated  at  each  systole  by  forcible  pulsa- 
tions. The  forcible  contraction  of  the  left  ventricle  dis- 
placed the  arch  entirely,  and  these  displacements  were 
especially  noticeable  in  the  left  superior  arch.  This 
showed  that  the  aorta  but  feebly  resisted  the  pressure 
of  the  blood. 

AORTIC  STENOSIS 

Anatomical  findings  in  cases  of  aortic  stenosis  suggest 
that  the  changes  in  the  heart  ought  to  be  similar  to  those 
of  aortic  insufficiency.  These  changes  should  consist  of 
an  even  more  marked  enlargement  of  the  left  ventricle 
and  in  the  frequent  coexistence  of  lesions  of  the  aorta. 
That  is  in  point  of  fact  what  is  found  in  the  tracings. 

Orthodiagram  77  is  of  a  patient  forty  years  of  age  with 
serious  aortic  stenosis,  with  no  sign  of  cardiac  insuffi- 
ciency. The  point  to  be  noted  here  is  the  excessive  devel- 
opment of  the  volume  of  the  heart ;  the  longitudinal  diam- 
eter measures  17.5  cm. ;  the  horizontal,  17.8  cm. ;  the  aorta 
shows  no  lesion.  In  this  case  the  clinical  diagnosis  was 
apparent  and  radioscopy  confirmatory. 


Fig.  77.     AORTIC  STENOSIS  WITHOUT  AORTITIS.     MAN  40  YEARS 

OF  AGE 


112 


THE  HEART  AND  THE  AORTA 


It  is  not  always  so.  Often  it  is  difficult  to  know  whether 
or  not  aortic  stenosis  exists,  for  the  systolic  murmur  at 
the  base  is  difficult  to  interpret,  and  hypertrophy  of  the 
left  ventricle  always  present  in  this  disease  is  not  suffi- 
ciently marked  to  be  obtained  by  palpation  or  percussion. 
It  is  in  such  cases  that  radiology  is  most  effective,  and 
several  times  in  debatable  cases,  aortic  stenosis  had  to 
be  determined  by  the  single  fact  that  screen  examination 
demonstrated  the  presence  of  a  left  ventricular  hyper- 
trophy. 


Fig.  78.    AORTIC  STENOSIS.    DILATATION  AND  FORCIBLE  PULSA- 
TION OF  THE  AORTA.     YOUTH  17  YEARS  OF  AGE 


This  examination  leads  to  other  findings  which  have  an 
important  bearing  on  the  prognosis  of  aortic  stenosis, 
which  varies  according  as  the  lesion  is  simple  or  accom- 
panied by  more  or  less  extensive  changes  of  the  aorta. 
These  findings  should  be  interpreted  with  great  care,  as 
the  following  case  shows. 

A  youth  seventeen  years  of  age  affected  with  aortic 
stenosis  as  shown  by  a  systolic  murmur  at  the  base.  The 
orthodiagraphic  tracing  (Fig.  78)  confirmed  the  diagno- 
sis, for  all  the  objective  signs  were  characteristic.     On 


VALVULAR  AFFECTIONS 


113 


superficial  examination,  it  might  have  been  thought  that 
there  were  at  the  same  time  marked  lesions  of  the  vessel, 
which  would  have  given  an  unfavorable  prognosis.  In  the 
frontal  position,  an  evident  enlargement  of  the  arch  was 
observed,  its  total  transverse  diameter  being  7.5  cm. 
instead  of  4  or  5  cm.,  the  normal  figure.  However,  in  the 
right  anterior  oblique  position  the  enlargement  was 
barely  appreciable,  for  the  diameter  of  the  aorta  meas- 
ured only  2.2  cm.,  which  is  but  a  slight  deviation  from  the 
physiological.  On  the  screen,  the  arch  of  the  aorta  was 
greatly  dilated  at  each  systolic  pulsation  and  in  the  course 
of  full  pulsations  its  walls  deviated  5  or  6  mm.  from  their 
normal  position  of  rest.  The  necessaiy  conclusion,  then, 
was  that  the  increase  in  volume  of  the  aorta  was  due  to  a 
functional  dilatation  rather  than  to  a  permanent  dilata- 
tion, that  the  arterial  walls  had  retained  all  their  elastic- 
ity, which  led  to  a  revision  of  the  dubious  prognosis  re- 
sulting from  the  first  examination.  In  this  connection, 
insistence  should  be  made  on  the  value  of  fluoroscopic 
examination,  as  conclusive  information  is  thus  obtained. 
If  a  radiographic  tracing  only  had  been  taken,  there  is  no 
doubt  that  it  would  have  been  found  like  Fig.  78,  and  that 


Fig.  79.     AOETIC  STENOSIS  WITH  AORTITIS.     MAN  56  YEAES  OF 

AGE 


114 


THE  HEART  AND  THE  AORTA 


a  serious  lesion  of  the  aorta  would  have  been  suspected 
which,  in  point  of  fact,  did  not  exist. 

On  the  other  hand,  when  aortic  stenosis  is  accompanied 
by  aortitis  affecting  the  thoracic  aorta  in  its  visible  por- 
tion, a  tracing  is  obtained  analogous  to  that  of  Fig.  79, 
which  leaves  no  room  for  doubt.  This  figure  is  of  a  man 
fifty-six  years  of  age  with  aortic  stenosis.  The  tracing 
shows  hypertrophy  of  the  two  ventricles,  especially  of  the 


Fig.  80.     DOUBLE  AOETIC  LESION.     MAN  59  YEAKS  OF  AGE 


\ 


left,  and  in  addition  a  uniform  enlargement  of  the  aortic 
shadow,  in  the  frontal  and  oblique  position.  On  the 
screen,  this  dark  shadow  shows  no  marked  pulsations. 
The  contrast  between  this  case  and  the  preceding  gives 
information  of  practical  value. 

These  indications,  diagnostic  of  one  or  the  other  of  the 
valvular  lesions  of  the  aorta,  may  be  equally  instructive 
in  the  diagnosis  of  associated  lesions  (Fig.  80).  They 
permit  of  the  determination  of  the  signaletic  state  of  the 
aorta  which  is,  in  this  case,  usually  altered.  They  will 
be  studied  in  more  detail  in  one  of  the  following  chapters 
(see  Aortitis,  Chap.  VIII). 


CHAPTER  V 

CONGENITAL  AFFECTIONS  OF  THE  HEART 

RADIOLOGY  plays  a  more  or  less  important  part  in 
the  diagnosis  of  congenital  lesions  of  the  heart.  This 
diagnosis  is  ordinarily  easily  made  when  it  is  a  question 
of  the  most  common  lesion,  that  is,  stenosis  of  the  pul- 
monary artery  with  inter-ventricular  perforation;  it  is 
on  the  contrary  very  difficult  when  it  is  a  question  of  mal- 
formations which  on  auscultation  and  percussion  give  no 
sign  or  when  they  result  from  disturbances  in  the  respec- 
tive positions  of  the  several  cavities.  Radiology  does  not 
attempt  to  remove  all  uncertainties,  and  it  is  true  that  it 
cannot  demonstrate  the  persistence  of  patent  ductus 
arteriosus,  the  transposition  of  the  great  vessels,  etc.; 
but  in  demonstrating  the  modifications  which  certain  mal- 
formations impress  on  the  configuration  of  the  heart,  it 
allows  at  least  suspicion  as  to  the  cause. 

To  complete  the  study  which  has  just  been  undertaken, 
it  is  necessary  to  accumulate  observations,  to  compare 
them  with  each  other,  and  to  draw  conclusions  which  will 
facilitate  further  research.  A  report,  therefore,  of  the 
cases  examined  and  of  the  indications  furnished  by  radio- 
logical examination  will  be  given  in  the  following  chap- 
ters. 

I.     STENOSIS    OF    THE    PULMONARY    ARTERY    WITH    INTER- 
VENTRICULAR PERFORATION 

This   affection,  the  most  frequent  of  the  congenital 
lesions,  is  ordinarily  revealed  by  cyanosis  from  birth, 
increasing  progressively  as  time  goes  on,  and  accompa-     \j 
nied  by  more  or  less  pronounced  dyspnoea.     Palpation 


116      THE  HEART  AND  THE  AORTA 

gives  a  systolic  thrill,  in  two  areas,  one  at  the  origin  of 
the  pulmonary  artery,  the  other  at  the  median  region  of 
the  heart.  Auscultation  gives  a  rough  systolic  murmur, 
in  the  second  intercostal  space,  transmitted  toward  the 
left  clavicle,  and  sometimes  another  murmur,  also  sys- 
tolic, of  deeper  tone,  heard  at  its  maximum  in  the  third 
intercostal  space  and  transmitted  transversely  toward 
the  axilla. 

However,  these  signs  are  not  constant  and  the  inter- 
pretation of  them  is  difficult,  especially  in  inter-ventricu- 
lar perforation  associated  with  stenosis  of  the  pulmo- 
nary artery,  a  communication  most  difficult  to  determine. 
In  these  cases  radioscopic  examination  gives  precise 
information,  as  the  following  show: 

1.  Mme.  M.,  age  twenty-five  years,  dyspnoea  on  exer- 
tion from  early  infancy.  Dyspnoea  has  increased  for  sev- 
eral years  and  causes  paroxysms  which  oblige  the  patient 
to  go  to  bed  for  weeks  and  months  at  a  time.  No  cyanosis 
evident.  Examination  of  the  eyes  (Dupuy-Dutemps 
method)  does  not  reveal  retinal  cyanosis ;  but  the  arteries 
are  darker  than  normal.  No  oedema  of  the  legs.  No  dis- 
turbance with  elimination  of  chlorides.  Blood  examina- 
tion: EC  =  3,910,000;  WC  =  14,000. 

On  examination  of  the  heart  a  slight  systolic  thrill  is 
noticed  in  the  second  and  the  third  left  intercostal  space 
transmitted  transversally  toward  the  axilla.  Ausculta- 
tion gives  a  murmur  which  is  clearly  systolic,  rough  in 
the  second  space,  softer  in  the  third  and  fourth  spaces, 
transmitted  toward  the  clavicle,  the  neck,  the  axilla,  and 
sharply  audible  in  the  back  between  the  left  scapula  and 
the  vertebral  column. 

In  this  patient  the  clinical  diagnosis  of  stenosis  of  the 
pulmonary  artery  with  inter-ventricular  perforation  is 
obvious  by  the  combination  of  functional  symptoms  and 
objective  signs  characteristic  of  the  affection,  notwith- 
standing the  absence  of  congenital  cyanosis. 

The  orthodiagraphic  tracing  in  the  frontal  position 


CONGENITAL  AFFECTIONS 


117 


(Fig.  81)  shows  that  the  left  contour  presents  nothing 
abnormal,  that  the  apex  of  the  heart  rests  on  the  dia- 
phragm, from  which  it  separates  in  deep  inspiration. 
The  right  contour,  more  developed  than  in  the  normal 
state,  overlaps  considerably  the  medio-sternal  shadow. 
On  the  lower  part,  corresponding  to  the  right  ventricle, 
may  be  noted  ample  pulsations  of  the  cardiac  shadow. 

In  general,  however,  the  diameters  of  the  heart  are  not 
exaggerated. 


Longitudinal  diameter 

13      cm 

Horizontal 

.12.5  cm 

D'G 

10      cm 

Fig.  81.     MME.  M.,  25  YEAES  OF  AGE 

PULMONAEY  STENOSIS  AND  INTEE-VENTEICULAE 
PEEFOEATION 


In  this  figure,  however,  an  anomaly  exists  which  is 
important  to  note :  there  is  an  exaggerated  saliency  of  the 
median  arc  in  the  upper  part  at  the  level  of  the  pulmonary 
artery  shadow  (P).  The  cross  marked  on  this  figure 
corresponds  to  the  site  of  the  murmur  and  of  the  purring 
thrill. 

In  the  right  posterior  oblique  position  at  50  degrees 


118 


THE  HEART  AND  THE  AORTA 


(Fig.  82),  the  outlines  of  the  left  auricle  (OGr)  and  of  the 
left  ventricle  (VG)  present  nothing  abnormal.  On  the 
contrary,  in  the  retro-cardiac  clear  space  downward 
under  the  aortic  shadow  (A),  an  exaggerated  salience  of 
the  pulmonary  artery  (Pul)  is  seen. 

In  the  right  anterior  oblique  position  at  50  degrees 
(Fig.  83),  the  shadow  of  the  left  ventricle  is  normal,  but 
the  salience  of  the  pulmonary  artery  in  the  retro-sternal 
clear  space  is  considerable.  In  the  retro-cardiac  clear 
space  downward  below  the  aortic  shadow  (A),  an  exag- 
gerated projection  of  the  pulmonary  artery  is  seen 
(Pul),  with  an  increase  in  the  outline  of  the  right  auricle 
(OD)  and  with  an  enlargement  of  the  right  ventricular 
(VD)  shadow. 

The  findings,  therefore,  in  the  three  positions  give  simi- 
lar information:  the  left  ventricle  is  of  normal  dimen- 
sions ;  the  right  cavities,  especially  the  ventricle,  are  en- 
larged ;  finally,  the  pulmonary  artery  in  its  entire  visible 
portion  is  much  dilated. 


Fig.  82 


Fig.  83 


Fig.  82.     SAME  PATIENT,  IN  EIGHT  POSTEEIOE  OBLIQUE  POSI- 
TION AT  50  DEGEEES 
A,  aorta.     Pul,  pulmonary  artery.     OG,  left  auricle.     VG,  left  ventricle. 

Fig.   83.     SAME  PATIENT,  IN  EIGHT  ANTEEIOE  OBLIQUE  POSI- 
TION AT  50  DEGEEES 


CONGENITAL  AFFECTIONS  119 

2.  Mile.  C,  twenty-five  years  of  age;  since  childhood 
subject  to  attacks  of  dyspnoea  which  had  become  almost 
incessant  so  that  she  had  had  to  stop  work  four  months 
previously.  Moderate  cyanosis  of  the  face  and  the  hands 
showing  more  when  active;  slight  retinal  cyanosis 
(Dupuy-Dutemps).  Blood  findings:  RC  =  4,200,000; 
WC  =  14,000. 


Fig.  84.     MLLE.  C,  25  YEARS  OF  AGE 

PULMONARY  STENOSIS  AND  INTER-VENTRICULAR 
PERFORATION 

Examination  of  the  heart  gives  a  very  intense  purring 
thrill  greatest  at  the  level  of  the  second  left  intercostal 
space ;  on  auscultation,  a  rough  systolic  murmur  is  heard 
all  over  the  precordial  region,  most  marked  at  the  level  of 
the  left  second  intercostal  space  and  transmitted  toward 
the  clavicle  and  to  the  back.  The  clinical  characteristics 
indicate  stenosis  of  the  pulmonary  artery  with  inter- 
ventricular perforation. 

Orthodiagraphic  examination  presents,  beside  the  gen- 
eral characteristics  common  to  this  lesion,  some  other 
changes.  In  the  frontal  position  (Fig.  84),  the  usual  en- 
largement of  the  pulmonary  arc  in  its  main  portion  is 
noticed.  But  especially  is  the  increase  of  the  cardiac 
shadow,  both  right  and  left  ventricle,  more  marked  here 
than  in  the  preceding  case.  The  shadow  of  the  aorta  dis- 
appears in  the  right  posterior  oblique  position  at  an  angle 


120      THE  HEART  AND  THE  AORTA 

of  40  degrees  instead  of  30,  the  normal  figure.    The  meas- 
urement of  the  diameters  is : 

Longitudinal  diameter  13     cm. 

Horizontal  12.5  cm. 

D'G  10.5  cm. 

In  the  oblique  positions  (OPD  and  OPGr,  Figs.  85  and 
86)  examination  shows  that  the  right  auricle  is  especially 
enlarged.  Finally,  a  slight  dilatation  of  the  right  ventri- 
cle was  observed  on  exertion.  The  result  was  that  if  these 
signs  confirmed  the  diagnosis,  they  demonstrated  also 
that  the  heart  by  reason  of  its  enlargement  and  increase 
of  the  right  cavities  was  beginning  to  show  signs  of 
failure  of  compensation. 

3.  Mile.  Mo.,  twenty-three  years  of  age,  presents  also 
subjective  and  objective  signs  characteristic  of  congenital 
lesion  of  the  pulmonary  artery. 

Examination  of  the  tracing  (Fig.  87)  shows  that  the 
pulmonary  arc  or  the  median  arc  is  considerably  devel- 
oped, which  is  evidence  of  dilatation  of  the  pulmonary 
artery  to  a  very  marked  degree.  On  the  other  hand,  the 
contour  of  the  left  ventricle  is  strongly  accentuated,  the 


Fig.  85.    SAME  PATIENT  AS  FIG.  84,  IN  EIGHT  POSTERIOR 
OBLIQUE  POSITION  AT  50  DEGREES 

Fig.  86.    SAME  PATIENT,  IN  LEFT  POSTERIOR  OBLIQUE  POSITION 

AT  50  DEGREES 


CONGENITAL  AFFECTIONS 


121 


right  contour  itself  is  exaggerated  and  all  the  diameters 
are  increased :  the  longitudinal  diameter  and  the  horizon- 
tal measure  15  cm. ;  the  line  D'G,  12.6  cm.  The  apex  of  the 
heart,  pushed  sharply  outward  and  slightly  lowered,  dis- 
appears in  the  right  posterior  oblique  position  at  an  angle 
of  50  degrees.  The  conclusion  is  then  that  the  effect  of  the 
lesion  on  the  heart  is  much  more  manifest  than  in  the 
preceding  cases. 


Fig.  87.     MLLE.  MO.,  23  YEARS  OF  AGE 

PULMONARY  STENOSIS  AND  INTER-VENTRICULAR 
PERFORATION 

4.  The  modifications  just  indicated  are  not  peculiar  to 
old  lesions,  and  are  found  in  very  young  children,  as  dem- 
onstrated by  the  orthodiagram  shown  in  Fig.  88,  which 


Fig.  88.     CHILD  17  MONTHS  OLD 

PULMONARY  STENOSIS  AND  INTER-VENTRICULAR 
PERFORATION 


122      THE  HEART  AND  THE  AORTA 

is  of  a  child  seventeen  months  old  with  congenital  cyano- 
sis, presenting  signs  ordinarily  characteristic  of  stenosis 
of  the  pulmonary  artery,  accompanied  by  inter-ventricu- 
lar  perforation.  In  a  general  way,  it  recalls  the  other 
tracings.  The  heart  is  pushed  outward,  the  development 
of  the  right  cavities  is  exaggerated  and  the  pulmonary 
arc  makes  an  abnormal  salience. 

The  radiological  data  in  the  case  of  stenosis  of  the  pul- 
monary artery  with  inter-ventricular  perforation  may 
be  summed  up  as  follows : 
QJ)     (a)  Exaggerated  development  of  the  shadow  of  the 
right  ventricle  and  often  of  the  right  auricle. 

(b)  No  increase,  or  slight  increase  at  the  beginning,  of 
the  contour  of  the  left  ventricle;  more  considerable  in- 
crease in  a  later  phase  of  the  disease. 
(s£/     (c)   Exaggeration  of  the  median  arc  or  the  pulmonary 
arc,  especially  in  its  superior  portion. 

The  first  two  findings  agree  with  the  pathology.  Both 
methods  of  examination  demonstrate  that  the  right  ven- 
tricle becomes  progressively  hypertrophied  in  order  to 
overcome  the  resistance  offered  to  the  blood  stream  by 
the  contraction  of  the  pulmonary  orifice,  and  that  in  the 
end  the  circulatory  difficulties  fall  upon  the  right  auricle. 
Though  the  left  auricle  shows  no  notable  changes  in  the 
beginning,  later,  however,  it  becomes  hypertrophied, 
especially  when  functional  disturbances  are  marked. 

Dilatation  of  the  pulmonary  artery  would  not  seem, 
according  to  anatomical  evidence,  to  constitute  a  constant 
symptom  of  this  disease,  though  it  has  been  noted  in  sev- 
eral cases.  But  radioscopic  examinations  showed  that  it 
was  never  lacking.  The  necessary  conclusion  from  this 
is  that  in  life  the  artery  is  much  distended,  but  that  this 
distension  rarely  results  in  a  permanent  dilatation,  so 
that  after  death  very  little  evidence  is  found  and  only  in 
a  very  inconstant  manner.  Later  this  interesting  ques- 
tion will  be  dealt  with  again. 


CONGENITAL  AFFECTIONS  12:3 

II.     SIMPLE  STENOSIS  OF  THE  PULMONARY  ARTERY 

Stenosis  of  the  pulmonary  artery  is  characterized 
solely  by  a  systolic  murmur  at  the  base,  intense,  vibrant, 
sometimes  rasping,  heard  in  the  left  second  intercostal 
space  and  accompanied,  on  palpation,  by  a  purring  thrill. 
It  is  transmitted  up  toward  the  left  clavicle,  but  is  absent 
in  certain  cases,  notably  when  stenosis  affects  the  vessel 
to  a  sufficiently  great  extent. 

On  percussion,  the  transverse  dullness  of  the  heart  is 
increased  and  overlaps  the  right  contour  of  the  sternum, 
which  indicates  a  more  or  less  marked  hypertrophy  of  the 
right  cavities. 

As  to  functional  signs,  they  are  extremely  variable.  If 
dyspnoea  is  frequent  with  palpitations  supervening  even 
during  rest,  cyanosis,  on  the  contrary,  is  very  inconstant 
and  may  even  be  absolutely  lacking. 

Three  observations  of  this  affection  are  presented 
here: 

1.  Child  fourteen  years  of  age  with  intense  cyanosis 
and  considerable  dyspnoea  with  paroxysmal  attacks. 
Localized  purring  thrill  at  the  left  second  intercostal 
space,  no  clear  murmur  heard. 

The  orthodiagraphic  tracing  of  this  patient  (Fig.  89) 
presents  the  characteristic  form  known  as  "en  sabot" : 
the  heart  apex  is  pushed  outward  and  elevated ;  below  it 


Fig.  89.     PULMONARY  STENOSIS 

p,  apex   of  the  left   heart;   p',  apex   of  the  right   heart. 
sabot. ") 


( Heart   ' '  en 


124 


THE  HEART  AND  THE  AORTA 


the  apex  of  the  right  ventricle  is  rounded  and  the  inferior 
contour  of  the  heart  descends  much  lower  than  normally. 
The  right  contour  greatly  overlaps  the  sternum.  In  the 
vicinity  of  the  diaphragm  very  ample  systolic  pulsations 
of  the  hypertrophied  right  ventricle  are  seen.  Finally, 
the  left  median  arc  or  pulmonary  arc  shows  an  abnormal 
salience  in  its  upper  part. 

2.  Nina  P.,  twenty-three  years  of  age,  with  Fried- 
reich's disease  (case  reported  by  Babinski),  gives  a  very 
localized  murmur  in  the  left  second  intercostal  space, 
transmitted  toward  the  clavicle.  Slight  tremor  attacks 
of  paroxysmal  tachycardia  with  syncope.  Slight  cyano- 
sis. 


Fig.  90.     NINA  P.,  23  YEAES  OF  AGE 
CONGENITAL  PULMONARY  STENOSIS 


The  orthodiagraphic  tracing  of  this  patient  (Fig.  90) 
presents  the  same  characteristics  as  the  preceding,  but 
with  the  following  differences :  a  greater  development  of 
the  heart,  apex  of  the  left  ventricle  elevated  and  pushed 
outward,  lower  contour  of  the  right  ventricle  exaggerated 
and  displacement  of  the  right  cavities  toward  the  right. 
The  diameters  are: 


Longitudinal  diameter 

15.4  cm 

Horizontal 

15.2  cm 

D'G 

11.9  cm 

CONGENITAL  AFFECTIONS 


125 


Finally,  the  median  arc  or  the  pulmonary  arc  makes  a 
considerable  salience. 

3.  Mile.  Mu.,  twenty  years  of  age;  systolic  murmur 
heard  in  the  second  left  intercostal  space,  purring  thrill, 
dyspnoea. 


Fig.  91.     MLLE.  MU.,  20  YEAES  OF  AGE 
CONGENITAL  PULMONAEY  STENOSIS 


Here  the  orthodiagraphy  characteristics  (Fig.  91)  are 
less  definite  than  in  the  first  two  tracings.  The  volume 
of  the  organ  is  nevertheless  exaggerated.  The  apex  of  the 
heart  is  pushed  slightly  outward  but  is  not  elevated.  The 
contour  of  the  left  ventricle  which  appears  rather  large 
does  not,  however,  indicate  that  the  cavity  is  increased. 
The  salience  of  the  left  ventricle,  in  fact,  is  not  abnormal 
in  the  right  posterior  oblique  position.  Hypertrophy  of 
the  right  ventricle  is  evident  exclusively  by  its  sharp 
projection  to  the  right  and  by  the  pulsations  (at  the  level 
of  the  arrow). 

The  diameters  are : 


Longitudinal  diameter 

12.8  cm 

Horizontal 

11.9  cm 

D'G 

10.1  cm 

The  median  arc  or  the  pulmonary  arc  is  manifestly 
exaggerated. 


126      THE  HEART  AND  THE  AORTA 

It  will  be  seen  that  in  the  case  of  simple  stenosis  of 
the  pulmonary  artery,  the  essential  data  obtained  by 
radiological  methods,  consist :  (1)  in  the  enlargement  of 
the  right  ventricle;^)  in  an  abnormal  salience  of  the 
pulmonary  arc,  a  salience  which  can  be  determined,  at 
least,  in  the  majority  of  cases;  ^(3)  in  the  absence  of 
apparent  modifications  in  the  volume  of  the  left  ventricle. 

The  enlargement  of  the  right  ventricle  is  a  constant 
fact;  besides,  pathological  anatomy  demonstrates  that  it 
is  seldom  lacking.  It  is  not  due  to  a  dilatation  of  the 
cavity,  but  to  a  real  hypertrophy  of  the  wall  described  by 
Moussous20  as  follows:  "The  ventricular  cavity  is  not 
very  voluminous,  it  contains  less  fluid  than  it  ought  to 
contain,  and  its  walls  are  extremely  thick.  The  columnae 
carneae  are  strongly  marked  as  well  as  the  papillary 
muscles.  The  muscular  development  assumes  an  unusual 
importance.  Sometimes  the  thickness  of  the  walls  is  due 
to  a  slight  sclerosis ;  there  is  diffuse  or  localized  myocardi- 
tis. Histological  studies  on  this  subject,  however,  are 
very  scant.  The  results  of  some  microscopic  examina- 
tions justify  the  statement  that  hypertrophy  properly  so 
called  is  the  principal  fact. ' ' 

As  for  the  dilatation  of  the  pulmonary  artery,  observed 
in  all  the  cases  which  we  have  studied,  and  which  is  not 
considered  as  persisting  after  death,  that  may  be  ex- 
plained in  different  ways:  in  the  first  place  it  can  be 
admitted  that  when  stenosis,  instead  of  being  limited  to 
the  orifice,  affects  to  a  great  extent  the  vessel,  there  is  no 
dilatation.  We  have  observed  a  case  of  this  type.  In 
others  it  is  fair  to  suppose  that  the  dilatation  must  have 
been  of  functional  origin  and  for  that  reason  was  not 
found  on  autopsy. 

The  absence  of  modifications  in  volume  of  the  left  ven- 
tricle is  easily  understood,  for  this  cavity  is  not  in  any 
way  concerned  in  the  lesion  which  affects  only  the  right 
heart. 

20  Moussous,  Maladies  congenitales  du  cceur.    Collection  .Leaute. 


CONGENITAL  AFFECTIONS  127 

III.     INTER-VENTRICULAR  PERFORATION 

This  condition,  which  has  been  described  by  Roger,-1  is 
accompanied  by  a  systolic  purring  thrill  at  the  level  of 
the  third  left  intercostal  space,  a  thrill  which  is  appar- 
ently lacking  when  the  patient  is  on  his  back,  but  which 
almost  always  reappears  in  left  lateral  recumbency. 
Auscultation  gives  a  systolic  murmur,  unchanging,  rough, 
intense,  high  pitched,  at  its  maximum  heard  in  the  inner 
part  of  the  third  intercostal  space  and  the  fourth  rib,  and 
which  is  transmitted  outward  but  diminishes  rapidly. 

On  percussion  there  is  an  increase  in  the  transverse 
dullness  of  the  heart.  There  are  generally  no  functional 
signs,  but  less  constantly  than  Roger  thinks,  for  in  a  cer- 
tain number  of  cases  dyspnoea  and  cyanosis  are  found, 
less  marked,  it  is  true,  than  in  the  preceding  cases,  and 
always  occurring  later.  Observations  of  such  cases  are 
presented  here : 

1.  Mile.  V.,  ten  and  one-half  years  of  age,  height  1.51 
m.,  weight  25  kilograms ;  apparent  health  entirely  normal. 
No  dyspnoea,  patient  can  run  without  the  least  discom- 
fort ;  there  is  no  trace  of  cyanosis.  Auscultation  gives  an 
intense  systolic  purring  thrill,  especially  in  left  lateral 
recumbency  at  the  level  of  the  third  intercostal  space, 
transmitted  outward  but  not  to  the  axilla. 

Radioscopic  examination  shows  a  heart  of  considerable 
volume  and  abnormal  in  form  (Fig.  92).  The  right  and 
left  contour  are  markedly  developed  on  both  sides  of  the 
medio-sternal  line.  Synchronous  systolic  pulsations  are 
visible  in  both  contours. 

The  diameters  are : 

Longitudinal  diameter  13.9  cm. 

Horizontal  14.6  cm. 

The  apex  of  the  heart,  markedly  globular,  is  pushed  out- 
ward and  elevated;  the  contour  of  the  right  ventricle  is 
rounded  below  the  diaphragm   during  inspiration  and 

2i  Roger,  Academie  de  Medecine,  1879. 


128      THE  HEART  AND  THE  AORTA 

projects  markedly  to  the  right.  The  right  ventricle  shows 
a  marked  hypertrophic  dilatation;  the  left  ventricle  is 
also  increased  in  volume. 

The  vascular  arcs  show  no  exaggeration. 

2.  Mme.  Sch.,  forty  years  of  age.  Subject  since  in- 
fancy to  attacks  of  dyspnoea.  For  some  time  these 
attacks  have  become  very  severe  and  frequent,  accom- 
panied by  palpitation,  pain  at  the  level  of  the  second  left 
intercostal  space,  and  extra-systolic  arhythmia.  No  cya- 
nosis. The  general  state  of  health  has  been,  nevertheless, 
fairly  satisfactory.  Six  confinements.  Three  children 
died  in  infancy. 

Examination  of  the  heart  shows  an  intense  systolic 
thrill,  localized  in  the  third  left  intercostal  space  and 
limited  to  this  space.  Cardiac  dull  area  slightly  enlarged, 
overlapping  the  sternum  at  the  base. 

On  auscultation,  there  is  heard  over  the  entire  precor- 
dial region  a  systolic  murmur,  rough,  rasping,  high 
pitched,  at  its  maximum  in  the  third  left  intercostal  space, 
near  the  sternum  and  transmitted  transversally  toward 
the  left ;  it  is  not  heard  under  the  clavicle. 

Fig.  93,  an  orthodiagraphic  tracing,  shows  a  cardiac 


Fig.  92.     MLLE.  V.,  10y2  YEAES  OF  AGE 

INTER-VENTRICULAR  PEKFORATION 

Very   large    globular   heart,    median,    equally    enlarged   right    and   left; 
ample  systolic  pulsations  on  both  sides. 


CONGENITAL  AFFECTIONS 


129 


area  markedly  developed  on  both  sides  of  the  medio- 
sternal  line,  left  contour  elongated,  convex,  rounded  apex 
descending  below  the  diaphragm  and  level  with  it  in  deep 
inspiration;  the  right  contour  projects  broadly,  especially 
in  its  upper  portion  (auricular).  At  the  level  of  the  arrow 
are  seen  ample  systolic  pulsations  of  the  hypertrophied 
right  ventricle. 


Fig.  93 


Fig.  94 


Fig.  93.     MME.  SCH.,  40  YEAES  OF  AGE 
INTEE-VENTEICULAE  PEEFOEATION 
A,  aorta;  P,  pulmonary  artery. 

Fig.   94.     SAME   PATIENT,  IN  LEFT  POSTEEIOE  OBLIQUE   POSI- 
TION AT  62  DEGEEES 


The  vascular  arcs  are  moderately  accentuated  and  pul- 
sate very  actively.  The  aorta  and  the  pulmonary  artery 
do  not  appear  dilated. 

In  the  left  posterior  oblique  position  the  clear  space 
appears,  much  reduced,  at  an  angle  of  62  degrees.  The 
outline  of  the  heart  indicates  an  enlargement  both  of  the 
right  auricle  and  of  the  right  ventricle  (Fig.  94). 

In  the  right  posterior  oblique  position,  the  apex  of  the 
heart  disappears  at  the  slightly  wide  angle  of  35  degrees. 


130      THE  HEART  AND  THE  AORTA 

In  another  case,  on  account  of  the  existence  of  a  systolic 
murmur  heard  entirely  in  the  central  region  of  the  heart, 
a  diagnosis  of  inter-ventricular  perforation  without 
stenosis  of  the  pulmonary  artery  was  affirmed  by  radio- 
scopic  examination  with  certain  reservations.  This  trac- 
ing (Fig.  95),  in  fact,  shows  that  the  heart  is  markedly 
developed  on  both  sides  of  the  medio-sternal  line,  as  in 
the  preceding  cases,  and  that  the  hypertrophy  of  the  right 
ventricle  is  greater  than  that  of  the  left  ventricle ;  but,  on 
the  other  hand,  an  enlargement  of  the  left  median  arc  is 
observed  indicating  a  slight  dilatation  of  the  vessel.  The 
patient  was  also  slightly  cyanotic.  Therefore  after  hav- 
ing affirmed  clinically  the  absence  of  stenosis  of  the  pul- 
monary artery,  finally,  on  radioscopic  examination,  an 
opinion  was  given  that  alteration  of  the  pulmonary  artery 
was  present. 


Fig.  95.     ALBERT  D.,  33  MONTHS  OF  AGE 

POSITIVE  INTER-VENTRICULAR  PERFORATION 

Pulmonary  stenosis  probable  because  of  the  marked  salience  of  the 
median  arc. 

Besides  these  cases,  in  which  the  radiological  aspect 
of  the  heart  has  very  definite  characteristics,,  patients  are 
found  affected  with  Roger's  disease,  in  whom  orthodia- 
graphic  examination  demonstrates  only  a  slight  influence 
of  the  lesion  on  the  volume  of  the  heart.  The  slight 
hypertrophy  of  the  two  ventricles  can  be  shown  as  fol- 
lows :  convex  left  contour ;  apex  pushed  outward,  slightly 
elevated  and  globular ;  inferior  contour  of  the  right  heart 
lowered ;  right  outline  overlapping  the  pulmonary  field  to 
some  extent;  horizontal  diameter  slightly  greater  than 


CONGENITAL  AFFECTIONS 


131 


the  longitudinal.  Finally,  as  in  other  observations,  no 
changes  in  the  vascular  arcs.  The  cardiogram  (Fig.  96) 
represents  this  aspect  of  the  heart. 

It  is  to  be  noted  also  that  the  importance  of  the  changes 
is  not  always  in  relation  to  that  of  the  lesions.  The  exte- 
rior configuration,  however,  conforms  in  all  respects  to 
the  anatomical  changes  of  the  septum  which  has  been 
described. 


Fig.  96.     DEL.,  32  YEAES  OF  AGE 
INTEE-VENTEICULAE  PEEFOBATION 


To  summarize,  therefore,  the  findings  in  Roger's  dis- 
ease, the  radioscopic  characteristics  are  as  follows : 
v  1.  The  cardiac  shadow  usually  shows  an  increase  as  a 
whole  and  is  developed  equally  on  both  sides  of  the  medio- 
sternal  line ;  however,  hypertrophy  of  the  right  ventricle 
is  more  important  than  that  of  the  left  ventricle.  In  some 
less  characteristic  cases,  the  increase  in  volume  of  the 
heart  is  not  so  marked  and  the  outlines  are  scarcely  de- 
formed. Nevertheless,  the  usual  signs  of  hypertrophy  of 
the  two  ventricles  are  found. 

V  2.     Clear,  full  pulsations  of  the  left  and  right  contour 
may  be  demonstrated. 
J  3.     There  is  no  change  in  the  vascular  arcs. 

In  a  general  way  these  data  confirm  the  pathological 


132      THE  HEART  AND  THE  AORTA 

findings  which  show  that  cardiac  hypertrophy  chiefly 
affects  the  right  ventricle.  However,  Merklen  has  de- 
clared that  there  is  in  addition  a  rather  marked  dilatation 
of  the  pulmonary  artery,  as  in  the  cases  in  which  there 
is  stenosis  of  the  orifice.  The  last  observation  would  seem 
to  confirm  this  statement  of  Merklen,  but  it  may  be 
pointed  out  that  this  observation  has  not  seemed  con- 
vincing and  that  on  this  point  some  reservations  had  to 
be  made  relative  to  the  possible  coexistence  with  inter- 
ventricular perforation  of  a  lesion  of  the  pulmonary 
artery.  Perhaps  the  same  was  true  in  the  cases  observed 
by  Merklen. 

IV.     CONGENITAL  AORTIC  STENOSIS 

Congenital  stenosis  of  the  aorta  presents  in  a  general 
way  the  same  objective  signs  as  acquired  aortic  stenosis : 
purring  thrill  more  or  less  marked  at  the  area  of  the  ori- 
fice, systolic  murmur  transmitted  toward  the  right  clavi- 
cle, marked  enlargement  of  the  left  ventricle.  The  func- 
tional signs  consist  in  the  early  appearance  of  palpitation, 
of  dyspnoea  on  exertion,  etc. 

In  a  case  which  was  examined,  radiological  investiga- 
tion confirmed  the  diagnosis,  and  determined  an  interest- 
ing detail,  the  significance  of  which  already  has  been  dis- 
cussed when  congenital  stenosis  of  the  pulmonary  artery 
was  considered,  namely,  dilatation  of  the  vessel  below  the 
lesion. 

Carmen  P.,  thirteen  years  of  age,  sickly  and  emaciated, 
of  keen  intelligence,  but  constrained  to  relative  immo- 
bility, the  least  movement  causing  attacks  of  palpitation 
and  dyspnoea.  These  disturbances  appeared  as  soon  as 
the  child  began  to  walk.  Examination  of  the  chest  shows 
the  existence  of  forcible  impulsive  pulsations  in  the  aortic 
region.  The  pulsations  of  the  aorta,  perceptible  in  the 
sternal  notch,  are  accompanied  by  an  intense  thrill. 

The  orthodiagraphic  tracing  (Fig.  97)  shows  the  left 
contour  of  the  heart  convex  and  elongated ;  the  apex  is 


CONGENITAL  AFFECTION S 


133 


rounded,  depressed,  pushed  slightly  outward.  The  right 
contour  is  not  modified;  only  the  left  ventricle  is  hyper- 
trophied. 


Fig.  97  Fig.  98 

Fig.  97.     CAEMEN  P.,  13  YEARS  OF  AGE 

CONGENITAL    AORTIC    STENOSIS.      Hypertrophy    of    the    left    ven- 
tricle, dilatation  of  the  aorta. 

Fig.  98.     SAME  PATIENT,  IN  RIGHT  ANTERIOR  OBLIQUE 
POSITION 
Diameter  of  the  ascending  aorta:  1.8  cm. 

The  diameters  are : 


Longitudinal  diameter 

10.5  cm 

Horizontal 

9.5  cm 

D'G 

8.6  cm 

The  right  median  arc  and  the  left  superior  arc  are 
exaggerated,  and  in  the  frontal  position  this  corresponds 
to  an  enlargement  of  the  aortic  arch.  In  the  right  ante- 
rior oblique  position  (Fig.  98),  the  shadow  of  the  ascend- 
ing aorta  is  enlarged.  The  volumetric  description  of  the 
aorta22  by  the  method  of  the  three  dimensions  gives  the 
following  results : 

Transverse  diameter  5.5  cm. 

Chord  2.0  cm. 

Descending  aorta  1.8  cm. 

22  See  below  (Aortitis)  the  study  of  the  volume  of  the  aorta  by  the  three 
dimensions  method. 


134      THE  HEART  AND  THE  AORTA 

The  caliber  of  the  vessel  is  about  2  cm.,  a  figure  that  is 
high  for  a  girl  thirteen  years  of  age.  Finally,  rather  ample 
pulsations  along  the  aortic  walls  are  noted. 

The  pulmonary  artery  is  not  dilated,  the  left  median 
arc  is  normal;  pulsations  here  were  marked  and  more 
ample  than  those  of  the  aorta. 

The  result  of  this  observation  is  that  aortic  stenosis  is 
characterized  from  the  radiological  point  of  view  by 
hypertrophy  of  the  left  ventricle  and  dilatation  of  the 
aorta. 

Ventricular  hypertrophy  is  easily  understood  and 
agrees  with  the  pathological  findings.  As  for  the  dilata- 
tion of  the  aorta,  it  is  a  matter  for  discussion,  because  not 
ordinarily  found  in  autopsies.  It  is  very  probable  that  it 
is  to  be  explained  in  the  same  way  as  dilatation  of  the 
pulmonary  artery,  in  case  of  congenital  stenosis  of  the 
orifice,  and  that  it  is  due  to  a  distension  of  functional 
nature,  so  that  it  may  be  perceptible  during  life  but  not 
found  after  death,  though  it  has  been  noted. 

The  congenital  origin  of  aortic  stenosis,  therefore,  may 
be  suspected  in  a  young  patient  affected  with  this  lesion 
whenever  radioscopy  shows  more  or  less  marked  dilata- 
tion of  the  vessel.23 


V.     CARDIAC  ECTOPIA  AND  TOTAL  INVERSION  OF  THE 

VISCERA 

We  have  twice  observed  this  malformation,  which  is, 
moreover,  only  of  documentary  interest.  In  the  first 
case,  the  patient  was  affected  with  cardiac  ectopia  fol- 
lowing congenital  sternal  malformation.  Union  had  not 
taken  place  in  the  lower  three-quarters  of  the  body  of 

23  We  have  had  occasion  to  observe  other  cases  of  congenital  stenosis  of 
the  aorta  in  children.  The  radiological  characteristics  agreed  absolutely  with 
those  which  we  have  just  presented.  We  found  the  dilatation  of  the  vessel 
above  the  lesion,  such  as  described.  On  the  screen,  the  aorta  showed  very 
ample  pulsations. 


CONGENITAL  AFFECTIONS 


135 


the  sternum  with  separation  of  the  xiphoid  appendage. 
A  hernia  of  the  heart  resulted. 

Other  malformations  were  also  noted :  inter-ventricular 
perforation,  double  superior  vena  cava,  etc.  The  heart 
was  very  voluminous,  especially  because  of  the  hyper- 
trophy and  the  dilatation  of  the  right  cavities,  auricle  and 
ventricle.  The  aorta  was  small,  the  pulmonary  artery 
very  much  dilated.  These  findings  naturally  could  not 
have  been  obtained  until  after  death,  and  diagnosis  of  the 
ectopia  alone  was  made  during  life. 


Fig.  99.     CAEDIAC  ECTOPIA 

Inter-ventricular  perforation.    Marked  hypertrophy  of  the  right  ventricle. 

Radioscopic  examination  gave  only  a  very  incomplete 
image  of  these  multiple  malformations.  In  the  frontal 
position  (Fig.  99),  a  very  marked  development  of  the 
cardiac  shadow,  right  and  left  of  the  median  axis,  was 
noted.  In  the  left  posterior  oblique  position  at  50  de- 
grees (Fig.  100),  at  P  and  at  P'  two  centers  of  superim- 
posed pulsations  were  observed,  which  gave  the  impres- 
sion of  two  apices  of  the  heart.  In  fact,  it  was  the  apex 
of  the  left  ventricle  which  pulsated  at  P  and  the  lower 
edge  of  the  right  ventricle  at  P\  These  exceptional  obser- 
vations may  be  made  use  of  by  observers  in  analogous 
cases. 

The  second  case  was  a  question  of  dextrocardia  with 
total  inversion  of  the  organs.    Radioscopy  confirmed  the 


136 


THE  HEART  AND  THE  AORTA 


displacement  of  the  heart  and  showed  that  it  was  not  due 
solely  to  a  torsion  of  the  organ  at  the  base,  nor  to  cardiac 
fixation  caused  by  old  adhesions ;  in  short,  it  was  not  an 
acquired  dextrocardia.  All  the  relations  of  the  inverted 
heart  with  the  neighboring  organs  were  normal.  Radios- 
copy also  demonstrated  the  inversion  of  the  other  organs, 
which  is  the  rule  in  congenital  dextrocardia. 

Figure  101,  which  shows  this  anomaly,  is  taken  in  the 
frontal  or  direct  anterior  position ;  it  looks  like  an  ortho- 
diagram taken  in  the  dorsal  position.  The  apex  of  the 
heart  is  on  the  patient's  right,  the  ascending  aorta  on  the 
left,  the  arch  goes  from  left  to  right,  the  stomach  is  on 
the  right,  the  liver  is  on  the  left.  The  patient  was  sixty- 
two  years  of  age  and  has  been  able  to  lead  a  normal 
existence  up  to  the  present  time. 

These  cases  of  congenital  conditions  are  the  only  ones 
that  conclusions  can  be  drawn  from.    According  to  cer- 


FiG.   100.     CAEDIAC  ECTOPIA   SEEN  IN  THE  LEFT   POSTEEIOE 
OBLIQUE  POSITION  AT  50  DEGEEES 

P,  apex  of  the  left  ventricle;  P',  apex  of  the  right  ventricle;  B,  gastric 
air -bubble. 


CONGENITAL  AFFECTIONS 


187 


Fig.  101.     INVERSION  OF  THE  ORGANS 
B,  gastric  air-bubble;  F,  liver. 

tain  writers,  notably  Groedel,24  Anheim,  Hoffmann,25  the 
persistence  of  Botal's  duct  (ductus  arteriosus)  could  be 
equally  well  shown  by  the  particular  aspect  of  the  heart 
on  radioscopic  examination.  According  to  them,  the 
heart  with  this  lesion  would  keep  its  normal  dimensions, 
but  a  very  special  enlargement  of  the  median  arc  would 
exist,  which  corresponds,  as  is  known,  to  the  region  of  the 
pulmonary  artery,  of  the  auricula  and  the  left  auricle. 
Enlargement  of  the  upper  part  would  indicate  simply  that 
there  is  a  dilatation  of  the  pulmonary  artery,  whereas  a 
simultaneous  enlargement  of  the  inferior  part  which 
corresponds  to  the  left  auricle  would  favor  the  persistence 
of  Botal's  duct.  We  have  not  had  occasion  to  verify  this 
fact. 

24  Th.  et  Fr.  Groedel,  Sur  la  forme  de  la  silhouette  du  cceur  dans  les  affec- 
tions cardiaques  congenitales.  Deutsches  Arch.  f.  Klin.  Mediz.  B.  CTII,  13, 
juillet,  1911. 

25  Hoffmann,  L'examen  fonctionnel  du  cosur,  1911. 


138      THE  HEART  AND  THE  AORTA 

Up  to  the  present  time  the  persistence  of  the  ductus 
arteriosus  has  not  been  the  subject  of  conclusive  clinical 
evidence.  In  one  case  where  it  was  suspected,  it  existed, 
with  the  usual  signs  on  auscultation,  a  dilatation  affect- 
ing at  the  same  time  the  aorta  and  the  pulmonary  artery. 
These  data  and  de  la  Camp's  observations  of  the  ab- 
normal force  of  the  pulmonary  artery  pulsations  have 
only  a  documentary  value. 

The  study  of  the  radiological  findings  just  discussed  in 
the  diagnosis  of  congenital  lesions  of  the  heart  shows  the 
importance  of  the  information  furnished  radiologically 
in  cases  which  were  suspected  because  of  functional  and 
physical  signs  but  could  be  affirmed  only  with  certain 
reservations. 

Besides  these  cases  there  are  others  where  it  is  impos- 
sible to  specify  the  nature  of  the  cardiac  changes,  the 
existence  of  which  is  evident  as  cases  of  progressive  con- 
genital cyanosis,  accompanied  by  more  or  less  acute 
dyspnoea,  etc.,  in  which  by  auscultation  or  percussion  no 
diagram  of  the  configuration  of  the  heart  and  of  the 
lesions  can  be  even  approximately  established.  It  is  true 
that  these  signs  may  be  considerable,  and  it  is  known  that 
some  cases  with  extensive  stenosis  of  the  pulmonary 
artery  and  others  with  wide  inter-ventricular  openings 
may  not  give  any  auscultatory  signs.  In  some  of  these 
cases,  however,  radiology  demonstrates  sufficiently  so  that 
an  almost  positive  diagnosis  from  the  outline  of  the  heart 
and  its  vessels  can  be  made.  Some  of  the  most  convincing 
cases  are  given  here : 

Recently  one  of  us  with  Laubry  reported  to  the  Societe 
medicate  des  hopitaux26  a  case  of  a  patient  twenty-seven 
years  of  age,  since  infancy  affected  with  progressive 
cyanosis   accompanied  by  polycythemia    (seven  million 

26  Laubry  et  Bordet,  Vn  cas  de  cyanose  congenitale.  Signs  perepheriques 
marques,  signes  stethoscopiques  legers.  Nettete  de  I'^xamen  orthodia- 
graphique.    Soc.  med.  des  hopitaux,  13  octobre,  1911. 


CONGENITAL  AFFECTION S 


139 


red  corpuscles).  On  auscultation  no  abnormal  sound  was 
heard  except  a  slight  galloping  rhythm  on  the  right  and  a 
metallic  hardness  of  the  secondary  sound  at  the  pulmo- 
nary area.  In  the  frontal  position  (Fig.  102),  the  ortho- 
diagram showed  a  considerable  increase  of  the  area  of 
cardiac  projection,  also  a  marked  projection  of  the  right 
ventricle ;  the  amplitude  of  the  pulsations  was  marked  to 
the  right  of  the  sternum.  The  contour  of  the  ventricle 
descended  below  the  line  of  the  diaphragm  and  the  apex 
of  the  heart  was  elevated. 


Fig.  102.     MLLE.  B.,  CONGENITAL  CYANOSIS 

There  was  therefore  a  marked  concentric  hypertrophy 
of  the  right  ventricle.  The  left  ventricle  was  normal. 
Finally,  the  left  median  arc  showed  a  marked  enlarge- 
ment in  its  superior  portion,  which  indicated  a  dilatation 
of  the  pulmonary  artery. 

In  the  right  posterior  oblique  position  (Fig.  103),  the 
left  auricle  appeared  to  be  normal,  whereas  in  the  left 
posterior  oblique  position  (Fig.  104),  the  contours  of  the 
right  auricle  and  ventricle  formed  an  exaggerated  sali- 
ence. The  combination  of  these  signs  warranted  the  con- 
clusion that  a  pulmonary  stenosis  existed,  situated  pos- 
sibly at  the  level  of  the  valves,  but  also  extending  to  a 
considerable  portion  of  the  superadjacent  artery. 


140 


THE  HEART  AND  THE  AORTA 


At  the  beginning  of  this  chapter  it  was  stated  that 
radioscopy  applied  to  the  study  of  congenital  lesions  of 
the  heart  allowed  not  only  a  final  diagnosis  to  be  made 
that  had  been  doubtful  or  even  impossible,  but  that  the 
evolution  of  the  lesion  could  be  prejudged  by  the  nature 
of  the  evidence  which  it  could  furnish,  either  after  a  single 
examination  or  after  a  series  of  examinations.  By  re- 
ferring to  the  history  of  Mile.  C,  this  point  is  brought 
out.  (See  observation  No.  2.)  Case  of  stenosis  of  the 
pulmonary  artery  with  inter-ventricular  perforation 
(Figs.  84,  85,  86).  In  this  case  examination  of  the  ortho- 
diagraphic  tracings  (Fig.  105)  taken  before  and  after 
physical  activity  such  as  walking  quickly  and  lowering 
and  raising  the  body  several  times  in  succession,  showed 
a  very  sharp  variation  in  the  two  diameters  of  the  heart. 
Whereas  before  and  after  physical  exertion,  the  longitu- 
dinal diameter  did  not  vary,  the  horizontal  diameter 
increased  from  11.4  cm.  to  11.8  cm.,  while  diameter  D'Gr 
increased  from  10.5  cm.  to  11.2  cm.    This  difference  could 


Fig.  103  Fig.  104 

Fig.  103.     SAME  CASE,  IN  EIGHT  POSTERIOR  OBLIQUE  POSITION 
No  exaggerated  salience  of  the  left  auricle  (OG). 

Fig.  104.     SAME  CASE,  IN  LEFT  POSTERIOR  OBLIQUE  POSITION 
Exaggerated  salience  of  the  right  auricle  and  ventricle. 


CONGENITAL  AFFECTIONS 


14-1 


be  explained  only  by  the  enlargement  of  the  right  inferior 
arc  of  the  heart,  which  had  a  direct  relation  to  the  dilata- 
tion of  the  right  ventricle.  Radioscopy  allows,  therefore, 
the  opportunity  to  obtain,  at  the  outset,  the  first  signs  of 
cardiac  failure  which  later  developments  confirm. 


Fig.  105.     MLLE.    C,    PULMONARY    STENOSIS   WITH    INTER-VEN- 
TRICULAR PERFORATION 

Dotted  line  shows  the  right  contour  of  the  heart  after  physical  exertion. 


CHAPTER  VI 

RADIOLOGICAL  OUTLINE  OF  THE  HEART  IN  CER- 
TAIN  PATHOLOGICAL   CONDITIONS   NOT 
RESULTING  FROM  VALVULAR 
LESIONS 

I.     CARDIAC  HYPERTROPHY  AND  DILATATION 

CARDIAC  hypertrophy  is  not  due  exclusively  to  val- 
vular lesions.  It  may  be  due  to  other  causes,  the 
most  frequent  of  which,  according  to  many  writers,  is 
Bright 's  disease.  The  question  arises  as  to  whether  it  is 
the  direct  result  of  sclerosis  of  the  kidney,  as  Potain  be- 
lieves. This  is  probably  not  so  and  it  is  necessary  rather 
to  agree  with  Traube's  opinion  that  it  results  from  the 
arterial  hypertension  which  accompanies  this  disease. 
The  evidence  of  this  is  that  it  appears  in  patients  with 
hypertension  before  there  is  any  renal  lesion.  It  con- 
stitutes, therefore,  a  defensive  reaction  against  circula- 
tory disturbances,  whereas  dilatation  indicates  that  the 
resistance  of  the  heart  has  begun  to  fail.  The  interest 
there  is  in  knowing  the  degree  and  nature  of  the  enlarge- 
ment of  the  heart  in  patients  with  arterial  hypertension 
is  evident ;  it  is  here  a  question  of  prognosis  which  radios- 
copy is  better  able  to  make  than  any  other  method  of  in- 
vestigation, as  the  following  cases  show,  some  in  which 
arterial  hypertension  and  cardiac  hypertrophy  consti- 
tuted the  only  pathological  signs,  others  in  which  they 
were  complicated  with  confirmed  Bright 's  disease. 

Cardiogram  106  is  of  a  man  fifty  years  of  age  who 
suffered  from  painful  precordial  attacks  with  irradia- 
tions to  the  left  arm,  especially  when  exercising.     The 


RADIOLOGICAL  OUTLINE  OF  THE  HEART    148 

only  abnormal  sign  was  had  on  auscultation,  which  gave 
an  accentuation  of  the  second  aortic  sound.  Arterial 
tension  was  very  high,  being  22  cm.  on  the  sphygmograpli. 
Radioscopy  showed  that  the  aorta  was  not  affected,  but 
that  the  left  ventricle  was  enlarged.  In  Fig.  106,  the 
aortic  outline  is  much-  elongated,  the  apex  of  the  heart 
is  pushed  outward  and  rounded,  and  the  longitudinal 
diameter  is  considerably  increased. 


Fig.   106.     HYPEKTKOPHY  OF  THE  LEFT  VENTRICLE 
Hypertension.     Man  50  years  of  age. 

Fig.  107  gives  analogous  information  in  a  patient  whose 
clinical  symptoms  closely  resemble  those  of  the  preceding 
case :  attacks  of  angina,  arterial  hypertension  as  high  as 
27  cm.,  etc.  But  here  the  radioscopic  signs  were  much 
more  accentuated ;  the  left  contour  of  the  heart  was  mark- 
edly developed,  the  apex  was  pushed  outward  and  low- 
ered ;  the  longitudinal  diameter  measured  19  cm.,  the  hori- 
zontal diameter,  17  cm.  Moreover,  the  aorta  was  dilated 
and  elongated.    On  the  screen  it  was  particularly  dense. 

The  radioscopic  signs  are  still  clearer  when  arterial 
hypertension  is  accompanied  by  chronic  interstitial 
nephritis. 

Figs.  108  and  109  are  two  typical  cardiograms  of  renal 


144      THE  HEART  AND  THE  AORTA 

heart.  The  form  of  the  left  contour  seen  here  is  mark- 
edly convex  in  its  upper  third,  so  that  the  line  which 
marks  this  contour  takes  from  point  Gr  an  external  direc- 
tion with  superior  convexity.  The  apex  of  the  heart  is 
rounded,  globular,  and  pushed  somewhat  outward.  Point 
G  is  elevated  and  lies  higher  than  point  D.    In  short,  left 


Fig.  107.     MARKED  HYPERTROPHY  OF  THE  LEFT  VENTRICLE 
Very  high  tension.     Man  56  years  of  age. 

ventricular  hypertrophy  affects  especially  the  base  and 
the  middle  third  of  the  cavity  wall,  for  though  all  the 
diameters  of  the  heart  are  increased,  it  is  especially  the 
diameter  D'G  which  shows  the  most  apparent  increase. 

Besides  hypertrophy  of  the  left  heart,  sometimes  con- 
siderable hypertrophy  of  the  right  heart  occurs  in  pa- 
tients who  have  hitherto  shown  no  cardiac  manifestation. 
Lutembacher27  has  described  a  terminal  tricuspid  syn- 
drome which  appeared  in  the  course  of  fibrous  emphy- 
sematous lesions  of  the  lung,  of  chronic  bronchitis,  and 
of  fibrous  tuberculosis.    This  syndrome  is  characteristic 

27  Lutembacher,  Syndrome  tricuspidien  terminal  dans  les  lesions  chro- 
niques  du  poumon.  Archives  des  maladies  du  cceur,  de^  vaisseaux,  et  du 
sang,  avril,  1916. 


RADIOLOGICAL  OUTLINE  OF  THE  HEART    145 

of  a  cardiac  insufficiency  which  rapidly  becomes  chronic. 
Early  diagnosis  of  this  complication  therefore  is  of  great 
importance.  Radioscopic  examination  gives  early  evi- 
dence of  cardiac  failure  when  there  is  still  time  to  give 
proper  treatment. 

The  radiological  image  of  the  heart  is  "en  sabot." 
The  right  ventricle  is  very  large,  rounded,  occupies  the 


Fig.  108.  EENAL  HEAET.  MAN  57  YEAES  OF  AGE 


Fig.  109.  LAEGE  EENAL  HEAET.  MAN  50  YEAES  OF  AGE 


146      THE  HEART  AND  THE  AORTA 

whole  anterior  surface  of  the  heart  and  pushes  the  apex 
upward  and  outward,  thus  showing  the  lower  extremity 
of  the  right  ventricle,  which  is  normally  obscured  by  the 
shadow  of  the  diaphragm.  The  left  outline  of  the  heart, 
oblique  from  above  downward  and  from  within  outward, 
corresponds,  in  its  upper  half,  to  the  left  ventricle,  and 
in  the  lower  half,  convex  from  without  inward,  to  the 
right  ventricle.  Moreover,  an  exaggeration  of  the  upper 
part  of  the  median  arc,  corresponding  to  a  dilatation  of 
the  pulmonary  artery  is  often  noted,  due,  apparently,  to 
the  high  tension  of  the  smaller  blood-vessels. 

The  heart,  in  this  type  of  tricuspid  insufficiency,  is  like 
that  in  stenosis  of  the  pulmonary  artery.  Its  outline  is 
clearly  differentiated  from  that  observed  in  cases  of 
functional  tricuspid  insufficiency,  in  which  the  heart  is 
enlarged  in  its  transverse  diameter  as  a  result  of  dilata- 
tion which  affects  principally  the  right  auricle  and  in 
which  the  right  ventricle  is  much  less  affected. 

Finally,  when  hypertension  exists  of  the  larger  and 
smaller  blood-vessels  in  bronchitic  emphysematous  pa- 
tients, radioscopy  shows  the  "round  heart"  due  to  asso- 
ciated hypertrophy  of  the  right  and  left  ventricle.  All 
these  points  are  confirmed  by  autopsy.  Clinically  we  find 
the  signs  of  right  and  left  ventricular  cardiac  insuffi- 
ciency.28 

II.     CARDIAC  HYPERTROPHY  OCCURRING  IN  THE  AGED 

In  old  people  enlargement  of  the  heart  may  be  due 
exclusively  to  a  moderate  but  diffuse  sclerosis  of  the 
arterial  system  which  causes  special  deformations  which 
it  is  necessary  to  recognize  clearly. 

The  senile  heart  ordinarily  shows  the  peculiar  charac- 
teristics observable  in  Figs.  110  and  111.  The  left  con- 
tour is  convex  in  the  upper  third,  the  apex  is  globular, 
pushed  outward ;  the  heart  rests  on  the  diaphragm,  which 
gives  the  radioscopic  image  a  special  configuration. 

28Lutembacher,  loc.  cit.,  p.  30. 


RADIOLOGICAL  OUTLINE  OF  THE  HEART    147 

The  appearance  of  the  aortic  shadow  which  in  a  sense 
caps  the  heart,  gives  it  the  form  of  a  "  Phrygian  bonnet. ' ' 
The  artery  itself  is  slightly  dilated,  dense  and  elongated ; 
at  its  point  of  origin  it  encroaches  on  the  right  pulmo- 
nary field  and  its  arc  points  decidedly  outward  under 
the  left  clavicle. 


Fig.  110  Fig.  Ill 

Fig.  110.    SENILE  HEAET.    WOMAN  64  YEAES  OF  AGE 

Fig.   111.     APPEAEANCE   OF   SENILE   HEAET   IN  A  EELATIVELY 
YOUNG  MAN,  45  YEAES  OF  AGE 

In  the  course  of  the  examinations  we  have  been  struck 
by  the  fact  that  this  appearance  of  the  senile  heart,  so 
often  found,  is  not,  however,  exclusively  confined  to  old 
age.  We  have  met  it,  though  not  often,  in  patients  of 
middle  age ;  but  in  such  cases  close  observation  has  always 
shown  at  the  same  time  the  existence  of  pathological 
signs  of  cardiac  debility,  of  vascular  sclerosis  indicating 
a  real  though  not  severe  affection  of  the  circulatory 
system.  In  such  cases,  prematurely  old,  radiological 
investigation  has  shown  changes  which  might  be  sus- 
pected but  the  nature  and  distribution  of  which  were  not 
shown  by  other  methods  of  examination. 

Cases  of  this  class  warrant  the  statement  that  deforma- 
tion of  the  heart  in  the  old  cannot  be  considered  as  simply 
physiological  and  analogous  to  those  we  have  just  de- 


148      THE  HEART  AND  THE  AORTA 

scribed.  The  causes  have  not  been  completely  studied, 
but  their  effects  are  certainly  due  to  a  pathological 
condition. 

III.     CARDIAC  DILATATION 

It  has  frequently  occurred,  in  the  course  of  our  studies, 
that  examples  of  dilatation  of  the  heart  have  been  found 
affecting  either  the  left  or  right  ventricle,  associated  with 
hypertrophy  of  one  or  the  other  of  these  cavities.  Usually 
these  were  cases  threatened  with  cardiac  insufficiency, 
and  radioscopic  examination  only  confirmed  the  clinical 
findings. 

However,  there  are  cases  in  which  moderate  dilatation 
of  the  heart  is  hardly  perceptible  by  the  ordinary  methods 
of  examination,  but  in  which  prognosis  is  of  great  im- 
portance and  which  calls  for  early  therapeutic  attention. 
These  are  cases  with  Bright 's  disease  or  patients  with 
valvular  lesions  in  whom  only  a  slight  murmur  is  found, 
dyspnoea  slightly  more  accentuated  than  usual,  without 
notable  organic  reaction.  It  is  very  important  there- 
fore to  recognize  such  cardiac  dilatation  as  soon  as  it 
appears  in  order  that  the  required  therapeutic  measures 
be  immediately  adopted.  Radioscopy  is  here  the  prefer- 
able method  of  determining  the  existence  of  cardiac 
dilatation,  however  slight  it  may  be,  when  percussion  and 
palpation  fail.  The  information  is  of  still  more  value  if, 
after  several  radioscopic  examinations  have  been  made 
of  the  same  patient  without  giving  new  indications,  the 
cardiac  shadow  is  suddenly  seen  to  change  and  assume 
the  particular  configuration  which  is  symptomatic  of 
dilatation  of  one  or  the  other  of  the  cavities. 

Still  more  interesting  are  the  radioscopic  findings  in 
cases  in  which  there  is  no  valvular  lesion  and  in  which 
there  has  not  previously  been  recognized  a  ventricular 
hypertrophy  associated  with  some  general  circulatory 
disturbance,  but  where  signs  of  cardiac  failure  are  found 
of  uncertain  origin  and  degree. 


RADIOLOGICAL  OUTLINE  OF  THE  HEART    149 

Without  recurring  here  to  the  question  of  functional 
insufficiency,  which  was  treated  in  another  chapter,  it  is 
well  to  recall  that  cardiac  dilatation,  when  it  reaches  a 
certain  stage,  causes  patency  of  the  auriculo-ventricular 
orifice  of  the  left  as  well  as  of  the  right  side.  Mitral  in- 
sufficiency is  not  always  caused  by  an  infectious  endo- 
carditis. There  are  many  cases  in  which  it  appears  only 
as  an  epiphenomenon  in  the  course  of  cardiac  dilatation. 
In  these  circumstances  the  important  thing  to  know  is 
the  precise  degree  of  this  dilatation,  even  more  than  the 
existence  of  a  systolic  murmur  at  the  apex.  Though 
auscultation  enables  a  diagnosis  of  this  murmur  to  be 
made,  it  is  incapable  of  revealing  the  pathogenic  condi- 
tions which  have  produced  it.  It  is  probable  also  that 
the  evolution  of  the  disease  may  give  the  impression  that 
the  murmur  is  of  organic  or  functional  origin;  but  if  to 
this  uncertain  information  the  idea  of  a  rapidly  devel- 
oped cardiac  dilatation  is  added  in  a  patient  hitherto  free 
from  cardiac  affection,  then  the  study  will  be  simplified. 
Radioscopy  furnishes  here  information  which  aids  in 
interpreting  these  disputed  cases. 

The  following,  for  example  (Fig.  112),  is  the  ortho- 


FiG.  112.    ALCOHOLIC  MYOCARDITIS.    MAN  52  YEARS  OF  AGE 


150      THE  HEART  AND  THE  AORTA 

diagram  of  a  man  fifty-two  years  of  age,  free  from  cardiac 
disease  in  his  youth,  who  for  some  months  past  has  suf- 
fered from  slight  dyspnoea  on  exertion.  For  fifteen  days 
the  dyspnoea  had  been  severe,  continuous,  and  provoked 
by  the  slightest  exertion;  the  face  was  cyanotic,  the  ex- 
tremities slightly  cedematous;  the  pulse  was  very  rapid 
and  feeMe ;  the  systolic  pressure  did  not  exceed  12  centi- 
meters. It  is  evident  that  this  was  a  case  of  rapidly 
progressive  dilatation  of  the  heart.  Moreover,  percus- 
sion showed  that  the  right  cavities  overlapped  by  two 
finger-breadths. the  right  edge  of  the  sternum;  the  apex 
of  the  heart  was  lowered  and  pushed  outward.  On  aus- 
cultation the  sounds  were  dull,  and  there  was  a  manifest 
irregularity  of  the  pulsation  probably  associated  with 
constant  arhythmia.  The  history  showed  that  the  patient 
was  markedly  alcoholic  and  presented  all  the  symptoms 
of  it.  In  the  region  of  the  apex  also  a  slight  systolic 
murmur  was  heard,  due  to  mitral  insufficiency. 

This  case  may  be  interpreted  as  being  due  to  an  organic 
insufficiency  accompanied  by  acute  dilatation  of  the  car- 
diac cavities  or  it  may  be  thought  that  this  murmur  was 
due  only  to  a  functional  insufficiency  related  to  alcoholic 
myocarditis.  The  clinical  findings  just  described  point 
to  this  second  interpretation,  but  it  is  not  a  definite  con- 
clusion. On  the  other  hand,  radioscopic  examination,  by 
showing  an  enlargement  of  the  heart  in  all  its  diameters, 
indicated  that  the  heart  was  in  a  state  of  dilatation 
affecting  the  right  and  left  cavities.  Doubtless  the  mur- 
mur must  have  been  related  to  a  functional  insufficiency, 
which  had  supervened  in  the  course  of  an  acute  asystolia 
in  a  patient  with  alcoholic  myocarditis,  rather  than  to  an 
old  infectious  endocarditis  of  which  there  is  no  trace. 

If  the  dilatation  is  accompanied  by  a  considerable 
hypertrophy  of  the  right  and  left  ventricular  walls,  the 
radiological  appearance  is  that  of  a  large  globular  heart, 
a  typical  aspect  which  allows  of  a  diagnosis  of  myocar- 
ditis.   Fig.  113  is  an  example.    It  is  a  man  sixty-five  years 


RADIOLOGICAL  OUTLINE  OF  THE  HEART    151 

of  age  with  chronic  myocarditis  and  aortitis.  The  two 
principal  diameters  of  the  organ  are  exactly  the  same 
length  (18  centimeters) ;  the  contours  of  the  two  ven- 
tricles show  an  excessive  but  regular  convexity ;  the  apex 
of  the  heart  is  perfectly  rounded.  This  patient  died  of 
cardiac  insufficiency,  and  the  anatomical  evidence  was 
then  compared  with  the  orthodiagraphy  tracing;  this 
tracing  demonstrated  exactly  the  globular  development 
of  the  organ. 


Fig.  113.    ALCOHOLIC  MYOCARDITIS.     MAN  65  YEAES  OF  AGE 

When  the  dilatation  is  very  marked,  it  is  not  unusual 
to  find  a  murmur  of  tricuspid  insufficiency  associated  with 
the  murmur  of  mitral  insufficiency.  This  is  shown  in  Fig. 
114,  where  the  dilatation  affects  all  the  cavities  equally, 
but  especially  the  right  cavities  including  the  auricle.  In 
this  case  the  right  contour  of  the  heart  shows  an  extreme 
development  from  the  cardio-vascular  angle  to  the  level 
of  the  diaphragm. 

The  radiological  signs,  therefore,  of  cardiac  dilatation 
are  characterized,  at  the  outset,  by  a  total  increase  of 
the  area  of  the  heart  and  its  diameters  (Fig.  112) ;  at  a 
more  advanced  stage  the  form  of  the  shadow  becomes 
perfectly  globular  with  equal  exaggeration  of  both  diame- 


152      THE  HEART  AND  THE  AORTA 

ters  (Fig.  113) ;  finally,  when  the  dilatation  reaches  a  con- 
siderable degree,  the  outlines  of  the  heart  assume  a  tri- 
angular aspect  with  the  base  resting  on  the  diaphragm 
(Fig.  115).  Other  signs  of  dilatation  as  shown  by  radios- 
copy are :  the  weakness  of  contractions  which  appear  in 
the  form  of  dragging  undulations,  and  a  peculiar  defor- 
mation of  the  contours  of  the  shadow  occasioned  by  dis- 
placement of  the  organ. 

In  the  following  chapter,  other  examples  will  be  found 
in  which  radioscopy  was  of  value  in  diagnosis  of  dilata- 
tion of  the  heart  and  in  the  prognosis  which  it  permits. 


Fig.  114.     ALCOHOLIC  MYOCAKDITIS 
Considerable  dilatation  of  the  right  cavities. 


IV.    BASEDOW'S  DISEASE 

The  prognosis  of  Basedow's  disease  is  closely  related 
to  the  condition  of  the  heart.  Patients  with  this  disease 
very  often  succumb  to  cardiac  disturbances.  For  a  con- 
siderable period  there  has  been  marked  interest  in  the 
nature  of  the  murmurs  which  are  so  commonly  heard; 
these,  according  to  some  writers,  are  usually  anorganic, 
while  others  think  they  are  related  to  functional  insuffi- 
ciencies, transitory  or  permanent. 


Fig.  115.    TELERADIOGRAPH  OF  A  CASE  OF  CAEDIAC  DILATATION 


RADIOLOGICAL  OUTLINE  OF  THE  HEART    153 

In  the  course  of  Basedow's  disease  murmurs  may  occur 
which  are  not  referable  to  any  change  in  the  orifices,  but 
the  number  of  these  cases  appears  more  limited  than 
Potain  states.  In  fact  these  murmurs  appear  only  in 
patients  with  severe  forms  of  the  disease,  in  whom  a 
certain  degree  of  cardiac  insufficiency  is  present.  The 
radioscopic  examinations  which  have  been  made  have, 
moreover,  confirmed  this,  for  they  have  shown  that  there 
was  always  a  more  or  less  notable  degree  of  cardiac 
dilatation  in  patients  with  these  murmurs. 

Fig.  116  is  the  cardiogram  of  a  patient  forty  years  of 
age  who  had  all  the  signs  of  Basedow's  disease.  The 
affection  was  severe,  tachycardia  was  very  pronounced, 
and  there  existed,  also,  with  dyspnoea  on  exertion,  a  pre- 
cordial distress  indicating  serious  circulatory  disturb- 
ance. On  percussion  the  heart  seemed  slightly  increased 
in  volume,  but  its  limits  did  not  appear  greatly  exagger- 
ated. Eadioscopy  showed  that  the  cardiac  dilatation  had 
reached  a  much  more  advanced  degree  than  was  sus- 
pected. The  right  and  left  contours  of  the  heart  were 
exaggerated  on  both  sides  of  the  median  line.  The  longi- 
tudinal diameter  measured  16.7  cm.,  the  horizontal,  16.4 
cm.  Moreover,  fluoroscopic  examination  showed  an  in- 
teresting change  seen  during  inspiratory  displacements 
of  the  heart.  The  left  contour,  deformed  in  its  middle 
third,  was  not  convex  but  concave,  as  if  the  ventricular 
wall  were  in  an  excessively  flaccid  condition.  This  condi- 
tion, especially  noticeable  during  inspiration,  and  par- 
ticularly in  the  recumbent  position,  appeared  to  be  related 
to  an  abnormal  flaccidity  of  the  heart  and  to  be  of  con- 
siderable prognostic  importance,  for  it  occurred  in  sev- 
eral cases  of  myocarditis  and  cardiac  insufficiency.  This 
impression  was  confirmed  by  the  rapid  and  feeble  pulsa- 
tions of  the  heart.  There  is  no  doubt  that  in  this  case 
radioscopic  examination  corrected  the  auscultatory  find- 
ings, for  the  impression  obtained  was  that  it  was  purely 


154 


THE  HEART  AND  THE  AORTA 


an  anorganic  murmur,  whereas  the  heart  was  seriously 
affected  and  the  prognosis  considered  to  be  very  grave. 

Fig.  117  furnishes  analogous  indications.  A  case  of 
a  woman  forty-nine  years  of  age,  with  marked  hyper- 
trophy of  the  thyroid  gland,  exophthalmia,  tachycardia 
and  the  heart  enlarged  on  percussion.    The  condition  of 


Fig.  116.    DILATATION  OF  THE  HEAET  IN  A  CASE  OF  BASEDOW'S 

DISEASE 

The  contour  in   dotted  lines  shows  the   deformation  of  the  left   outline 
during  deep  inspiration. 


Fig.  117.    BASEDOW'S  DISEASE.     FLACCID  HEAET 


RADIOLOGICAL  OUTLINE  OF  THE  HEART    155 

this  patient,  however,  was  complex.  There  were  symp- 
toms of  renal  origin :  albuminuria,  galloping  sound,  slight 
malleolar  oedema.  As  the  figure  shows,  the  area  of  pro- 
jection of  the  heart  is  notably  increased,  the  apex  is 
rounded,  lowered,  but  the  contour  of  the  left  ventricle  is 
not  convex  as  seen  in  the  renal  heart;  marked  concavity 
of  the  middle  third  of  the  left  contour  is  also  found,  the 
pulsations  rapid,  feeble  and  retarded.  Here  dilatation 
predominates. 

V.     ARHYTHMIC  HEART 

The  numerous  radiological  observations  made  of  pa- 
tients affected  with  arhythmia  have  led  to  some  interest- 
ing remarks  which  will  be  only  mentioned  in  passing.  It 
would  evidently  be  premature  to  say  that  characteristic 
outlines  exist  of  such  and  such  arhythmic  types,  for  these 
may  be  associated  with  very  diverse  cardiac  affections. 
Moreover,  radiology  should  not  be  compared  with  graphic 
recording  or  other  methods  of  examination,  to  demon- 
strate the  nature  of  an  arhythmia ;  but  it  is  always  worth 
while  to  use  the  results  of  fluoroscopic  examination  or 
orthodiagraphy  to  obtain  supplementary  information  the 
interpretation  of  which  may  lead  to  results  of  real  prac- 
tical value. 

We  have  examined  several  patients  with  paroxysmal 
tachycardia,  in  whom  during  the  course  of  this  arhythmia 
the  question  was  determined  whether  the  heart  was  en- 
larged. Certain  writers,  notably  Martius,  have  stated 
that  the  heart  was  larger  than  normal.  Hoffmann  has 
not  agreed  with  this  opinion.  A  case  is  presented  here 
which  shows  that  Martius'  opinion  is  erroneous.  Fig. 
118  represents,  in  the  black  lines,  the  orthodiagram  of  a 
woman  thirty  years  of  age,  with  paroxysmal  tachycardia 
of  auricular  origin,  whose  history  has  previously  been 
reported.29     The  tachycardia  was  unusual,  since  it  ex- 

29  Vaquez  et  Pezzi,  Tachycardie  paroxystique  de  type  auriculaire.  Societe 
medicale  des  hopitaux,  seance  du  22  mars,  1912,  p.  360. 


156      THE  HEART  AND  THE  AORTA 

ceeded  300  pulsations  a  minute.  During  the  attack,  as 
can  easily  be  seen,  the  heart  was  of  small  dimensions,  its 
longitudinal  diameter  measured  12.2  cm.  and  its  hori- 
zontal diameter,  12.1  cm. 


Fig.  118.    PAEOXYSMAL  TACHYCAEDIA 

Black  lines,  contour  during  the  attack;  dotted  lines,  contour  of  the  heart 
after  the  attack. 


A  second  examination  was  made  a  week  after  the  ter- 
mination of  the  attack,  the  patient  being  in  the  same 
recumbent  position  and  under  the  same  conditions  of 
examination.  As  the  orthodiagram  shows,  the  diameters 
of  the  heart  have  increased  or  rather  they  have  resumed 
their  normal  dimensions :  the  longitudinal  diameter  is 
13  cm.  and  the  horizontal  diameter  is  12.4  cm.  Moreover, 
on  the  screen,  the  pulsations,  almost  imperceptible  during 
the  attack,  had  become  ample  and  forcible. 

We  have  also  examined  several  other  patients  with 
paroxysmal  tachycardia  in  which  the  results  agreed  with 
these.  The  evidence  in  these  cases  has  been  sufficiently 
conclusive  so  that  it  is  believed  that  diminution  in  the 
volume  of  the  heart  in  the  course  of  an  attack  is  a  usual 
phenomenon. 

Chronic  arhythmia,  referred  to  as  auricular  fibrilla- 
tion, is  always  a  grave  symptom,  though  a  certain  num- 


RADIOLOGICAL  OUTLINE  OF  THE  HEART    157 

ber  of  cases  become  compensated  to  this  condition  and 
suffer  only  moderately  during  a  period  of  months  or 
years.  However,  when  it  occurs  in  cases  with  valvular 
lesions,  it  is  always  the  sign  of  cardiac  insufficiency,  the 
prognosis  of  which  is  based  on  the  condition  of  the  heart 
itself.  Electrocardiograms  and  jugular  tracings  indicate 
only  a  marked  modification  in  the  type  of  contraction  of 
the  auricle,  without  giving  information  as  to  the  condi- 
tion of  the  other  parts  of  the  heart.  Radioscopy  shows 
that,  together  with  cardiac  changes  consistent  with  the 
associated  valvular  lesion,  there  occur,  sometimes,  un- 
suspected changes  and  more  or  less  marked  dilatations 
which  must  be  considered  in  making  a  prognosis. 

The  orthodiagraph^  tracing  in  Fig.  119  is  of  a  man 
thirty-nine  years  of  age,  subject  for  a  long  time  to 
dyspnoea  on  exertion  and  palpitation.  He  had  been 
obliged  six  months  previously  to  give  up  his  work  as 
valet  because  the  symptoms  became  so  aggravated.  On 
examination  a  systolic  murmur  was  heard  at  the  apex 
and  at  the  same  time  a  complete  characteristic  arhythmia. 
After  some  days  of  rest  the  signs  of  cardiac  insufficiency 


Fig.  119.     CHEONIC  AEHYTHMIA 
Mitral  disease.    Dilatation  of  the  heart. 


158      THE  HEART  AND  THE  AORTA 

appeared  to  be  relieved  and  the  only  abnormal  sign  re- 
maining was  the  persistence  of  the  arhythmia.  With  only 
these  indications  it  would  have  been  difficult  to  determine 
the  prognosis,  since  chronic  arhythmia  does  not  consti- 
tute, as  we  have  just  said,  a  sufficient  sign  of  irremedi- 
able failure  of  the  heart.  But  radioscopic  examination 
showed,  on  the  contrary,  that  there  was  reason  for  con- 
sidering the  prognosis  as  very  grave. 

The  orthodiagram  reproduces  the  usual  image  of  a 
mitral  lesion,  which  was  also  recognized  by  auscultation ; 
but  it  demonstrates,  moreover,  an  enormous  development 
of  the  heart.  On  the  other  hand,  in  right  posterior 
oblique  position  at  50  degrees,  the  left  auricle  obscured 
the  retro-cardiac  clear  space,  and  at  this  angle  the  apex 
of  the  heart  did  not  disappear  behind  the  vertebral 
column.  There  was  reason  to  infer  then  the  existence 
of  a  marked  dilatation  of  the  heart  with  an  increase  of 
all  the  diameters.  Some  months  later  the  patient  re- 
entered the  hospital  with  severe  symptoms  of  asystolism. 

Irregularities  of  the  heart,  notably  paroxysmal  tachy- 
cardia and  chronic  arhythmia,  often  have  the  effect  of 
muffling  the  stethoscopic  signs  of  the  associated  valvular 
lesions.  Sometimes  it  is  the  chronic  arhythmia  which,  by 
modifying  profoundly  the  mode  of  contraction  of  the 
auricles,  suppresses  the  presystolic  rumbling  and  renders 
difficult  the  diagnosis  of  mitral  stenosis.  Sometimes  it  is 
the  paroxysmal  tachycardia  which,  by  a  very  different 
action,  weakens  the  orificial  murmurs  or  the  presystolic 
rumbling  to  such  an  extent  that  they  can  no  longer  be 
recognized  by  auscultation.  In  these  different  cases 
radioscopic  examination,  by  giving  the  characteristic  out- 
lines of  this  affection,  makes  possible  a  final  diagnosis. 
An  opportunity  was  given  to  examine  two  patients  with 
paroxysmal  tachycardia,  in  whom,  during  the  attacks,  it 
was  impossible  to  determine  whether  or  not  a  valvular 
lesion  existed.  Fluoroscopic  examination  showed  that 
the   patients   were   affected   with   mitral    stenosis;    the 


RADIOLOGICAL  OUTLINE  OF  THE  HEART    159 

diagnosis  was  confirmed  by  auscultation  when  the  crisis 
had  passed. 

VI.     CARDIAC  INSUFFICIENCY  AND  ASYSTOLISM 

We  have  had  an  opportunity  in  the  course  of  these  stud- 
ies to  observe  several  times  the  radioscope  signs  which 
enabled  us  to  make  a  diagnosis  of  cardiac  dilatation 
(which  usually  precedes  asystolic  symptoms  and  which 
accompanies  myocardial  insufficiency).  To  recognize  the 
early  dilatation  does  not  only  complete  a  diagnosis  but 
it  immediately  establishes  a  prognosis;  in  order  that  this 
prognosis  be  of  value,  it  must  not  be  based  only  on  the 
objective  and  subjective  functional  signs  which  are  ob- 
tained by  the  ordinary  investigation  methods :  peripheral 
stasis,  oedema  of  the  extremities,  enlargement  of  the 
liver,  marked  dilatation  of  the  right  cavities  with  tri- 
cuspid insufficiency,  etc.  This  prognosis  has  a  greater 
value  (since  it  leads  to  early  therapeutic  intervention) 
if  it  is  still  impossible  to  recognize  in  a  patient  the  symp- 
toms that  precede  cardiac  insufficiency.  In  such  cases 
as  has  been  shown,  radioscopy  gives  evidence  of  consid- 
erable importance.  We  merely  mention  the  many  cases 
in  which  early  dilatation  of  the  cavities  without  threaten- 
ing symptoms  was  revealed  by  radioscopy,  cases  in  which 
cardiac  debility  was  marked,  moreover,  by  the  modifica- 
tion and  retarding  of  pulsations  along  the  ventricular 
contours,  by  flaccidness,  and  slight  amplitude  of  the  myo- 
cardial contractions,  or  in  short  by  evidence  of  severe 
disturbances  in  the  cardiac  systole.  Myocardial  changes 
can  therefore  best  be  studied  by  radioscopy. 

Several  times  we  have  had  occasion  to  demonstrate  the 
marked  changes  in  the  exterior  appearance  of  the  heart 
and  to  make  an  unfavorable  prognosis  because  of  the 
progressive  cardiac  dilatation  and  of  the  early  appear- 
ance of  the  signs  of  asystolism.  The  different  degrees 
through  which  a  patient  passes  before  chronic  asys,tolism 
is  reached  could  be  determined  and  it  was  not  surprising 


160      THE  HEART  AND  THE  AORTA 

after  weeks  or  months  to  see  the  outline  of  the  cardiac 
shadow  change  completely  and  assume  the  form  of  pro- 
nounced asystolic  conditions.  This  is  shown  in  Fig.  120, 
a  man  thirty-nine  years  of  age  with  chronic  asystolism. 


Fig.  120.    ASYSTOLISM 

The  extreme  dilatation  of  all  the  cavities  is  shown  here 
as  is  seen  by  increase  of  the  diameters,  the  longitudinal 
being  21  cm.,  the  horizontal  being  22.5  cm.  The  enlarge- 
ments of  the  right  auricle  and  ventricle  are  indicated  by 
the  considerable  projection  of  the  left  contour,  which  is 
level  with  the  external  thoracic  wall ;  moreover,  the  right 
diaphragmatic  shadow  is  very  high  and  is  formed  by  an 
almost  horizontal  line,  which  indicates  an  enormous 
development  of  the  liver. 


CHAPTER  VII 

AFFECTIONS  OF  THE  PERICARDIUM 

A.     PERICARDIAL   EFFUSIONS 

THE  diagnosis  of  pericardial  effusions  should  be,  ac- 
cording to  some  writers,  relatively  easy.  It  is  not 
always  so  in  practice,  and  if  fluid  in  the  pericardial  cavity 
is  accompanied  ordinarily  on  palpation  by  elongation  of 
the  heart  apex,  on  percussion  by  increase  of  the  cardiac 
dullness,  and  on  auscultation  by  the  disappearance  of  the 
normal  sounds,  nevertheless  any  one  of  these  signs  may 
be  consistent  with  some  other  affection.  Radiological 
examination  is  then  of  great  value,  because  very  often  it 
shows  in  the  heart  outlines  peculiarities  which  make 
diagnosis  more  positive.  Unfortunately  it  is  not  always 
easy  to  proceed  with  such  an  examination,  for  it  requires 
perfect  radiological  equipment  and  special  precautions 
on  account  of  the  patient's  generally  serious  condition. 

Pericardial  effusions  bring  about  a  combination  of 
radiological  signs,  which  are: 

(a)  Globular  increase  of  cardio-pericardial  shadow.    * 

(b)  Peculiar  modifications  of  the  form  of  this  shadow.  J 

(c)  Diminution  and  sometimes  even  abolition  of  the  y/ 
cardiac  pulsations. 

(a)  The  increase __ of  the  cardio-pericardial  shadow  is 
sometimes  considerable;  the  pulmonary  fields  are  en- 
croached upon  by  a  shadowy  mass,  which  enlarges  from 
above  downward  and  is  at  its  maximum  at  the  level  of 
the  line  of  the  diaphragm.  The  result  is  an  unusual 
elongation  of  the  horizontal  diameter,  especially  as  com- 
pared with  the  longitudinal  diameter.     On  Fig.  121,  the 


162      THE  HEART  AND  THE  AORTA 

horizontal  diameter  is  19.5  cm.,  whereas  the  longitudinal 
does  not  exceed  17  cm.  This  fact,  which  is  rather  rare, 
although  it  may  be  found  in  cases  of  dilatation  of  the 
heart,  is  invariably  the  rule  in  effusions  of  the  pericar- 
dium, and  the  difference  between  the  two  diameters  is 
never  so  great  as  in  this  affection. 


Fig.  121.     PEEICAEDIAL  EFFUSION 

(b)  The  form  of  the  cardio-pericardial  shadow  has  a 
peculiarity  which  is  not  found  in  any  other  disease. 
First,  as  Dietlen  has  noted,  the  pedicule  is  very  short, 
that  is  to  say,  the  shadow  has  only  a  slight  development 
in  its  middle  portion,  upward  under  the  clavicle ;  more- 
over, from  this  point  downward,  the  contours  expand 
suddenly  right  and  left,  but  especially  to  the  left  where 
the  outline  of  the  shadow  takes  an  almost  horizontal 
position,  reaching  the  external  portion  of  the  thoracic 
wall  (Fig.  122). 

In  these  less  accentuated  cases  the  general  form  of  the 
cardio-pericardial  shadow  is  globular  and  similar  to  the 
image  seen  in  myocarditis  (Fig.  123). 

(c)  The  study  of  the  heart  pulsations  is  particularly 
suggestive,  and  even  in  the  cases  in  which  the  amount  of 
fluid  is  not  yet  abundant,  a  very  notable  decrease  of  the 
pulsation  is  noticed,  owing  to  the  fact  that  the  pulsation 
transmitted  in  all  directions  at  once  by  the  contact  of  the 


AFFECTIONS  OF  THE  PERICARDIUM 


1C3 


heart  with  the  fluid  cushion  arrives  much  weakened  at  the 
walls  of  the  pericardial  sac. 

However,  none  of  these  findings  is  pathognomonic  of 
an  effusion  in  the  pericardium.  But  if  all  three  coexist, 
the  diagnosis  is  usually  correct  independently  of  all 
negative  or  positive  clinical  signs.  Beclere30  has  been 
able  to  establish  radioscopically  the  diagnosis  of  chronic 
pericarditis  and  that  of  acute  pericarditis  with  effusion, 
in  cases  which  have  finally  been  confirmed  by  the  progress 
of  the  disease. 


Fig.  122  Fig.  123 

Fig.  122.    LAEGE  PEEICAEDIAL  EFFUSION 

Fig.  123.     MODEEATE  PEEICAEDIAL  EFFUSION,  OF  TEAUMATIC 

OEIGIN 


Nevertheless,  radiological  examination  is  not  always 
sufficient  to  form  a  positive  diagnosis,  notably  when  the 
amount  of  fluid  is  not  abundant  and  the  heart  is  very 
much  enlarged;  its  pulsations  are  then  transmitted  al- 
most entirely  to  the  limits  of  the  pericardial  sac. 

Inversely,  the  markedly  increased  shadow  of  the  heart 
due  to  cardiac  dilatations  may  be  mistaken  for  an  effu- 
sion, for  example,  in  alcoholic  myocarditis.  In  this  case, 
the  increase  of  the  cardio-pericardial  shadow  is  accom- 

soBeclere,  Traite  de  radiologie  du  Pr.  Bouchard,  1904. 


164 


THE  HEART  AND  THE  AORTA 


panied  by  more  or  less  marked  feeble  pulsations,  and  the 
combination  of  the  two  conditions  might  lead  to  a  diag- 
nosis of  fluid. 


Fig.  124. 


Black  lines  the  contour  of  the  shadow  when  the  patient  entered  the 
hospital;  dotted  lines,  contour  of  the  heart  a  month  and  a  half  later;  the 
effusion  reabsorbed. 


Lutembacher31  has  recently  reported  a  case  of  aneurism 
of  the  left  auricle  measuring  400  cu.  cm.  which  because 
of  the  considerable  dimensions  and  configuration  of  the 
radioscopic  tracing  had  been  mistaken  for  a  time  for  a 
pericardial  effusion.  But  in  the  case  of  cardiac  dilatation 
the  form  of  the  shadow  differs  from  that  of  effusion; 
moreover,  though  the  pulsations  may  be  slight  they  never 
disappear  completely;  in  a  word,  the  radiological  syn- 
drome described  above  is  not  found. 

Finally,  radioscopy  is  the  preferable  method  by  which 
to  study  thoroughly  the  development  of  pericardial  effu- 
sions. The  progressive  increase  in  the  quantity  of  fluid 
and  its  diminution  are  interpreted  by  variations  in  the 
form  and  the  diameters  of  the  shadows,  variations  which 
.are  easily  read  on  cardiograms  or  plates  without  defor- 
mations. Fig.  124,  a  man  forty-two  years  of  age  with  an 
exudative  pericarditis,  is  an  example  in  point.  The  con- 
si  Lutembacher,  Anevrisme  de  I'oreillette  gauche.  Archives  des  maladies 
du  eceur,  des  vaisseaux  et  du  sang,  avril,  1917. 


AFFECTIONS  OF  THE  PERICARDIUM  165 

tour  in  black  lines  shows  dimensions  of  the  cardio-peri- 
cardial  shadow  at  the  time  when  the  pericarditis  was  at 
its  height.  The  contour  in  dotted  lines,  taken  a  month 
and  a  half  later,  when  there  was  improvement,  indicates 
a  very  clear  diminution  of  this  shadow.  In  addition  the 
pulsations,  barely  perceptible  at  the  time  of  the  first 
tracing,  had  become  normal  at  the  time  of  the  second. 

B.     CARDIAC  SYMPHYSIS  AND  PARTIAL  ADHESIONS  OF  THE 
PERICARDIUM 

The  term  cardiac  symphysis,  which  designates  the  total 
adhesion  of  the  two  pericardial  folds,  is  also  applied  to 
adhesions  which  unite  the  outer  surface  of  the  pericar- 
dium to  the  neighboring  organs. 

The  multiplicity  of  anatomical  forms  of  symphysis 
explains  why  the  visible  signs  of  this  affection  are  so 
numerous  and  why  they  vary  according  to  the  location 
of  the  adhesions. 

What  is  of  utmost  importance  to  know  is  first  whether 
adhesions  of  the  pericardium  exist  and  then  whether  they 
are  generalized  or  localized;  whether  the  folds  of  the 
pericardium  are  simply  united  with  each  other ;  whether 
the  heart  is  still  mobile  or  is  fixed  to  the  costal  wall,  to  the 
diaphragm  and  to  neighboring  organs;  finally,  whether 
there  is  at  the  same  time  a  posterior  mediastinitis.  It  is 
the  more  important  to  solve  these  questions  because  the 
treatment  of  pericardial  symphysis  depends,  in  a  certain 
measure,  on  surgery,  and  before  proceeding  with  surgical 
intervention  it  is  indispensable  to  know  what  results  it 
may  have.  The  indications  and  the  counter-indications 
of  Brauer's  operation  can  be  fixed  only  by  radioscopic 
examination  of  the  adherent  heart.  This  accounts  for 
the  long  explanation  that  is  given  of  this  question. 

Pericardial  adhesions  cause  the  many  and  varied 
modifications  of  the  cardiac  image,  modifications  which 
may  be  called  immediate  or  mediate  according  as  they 


166      THE  HEART  AND  THE  AORTA 

are  in  direct  or  indirect  relation  with  the  adhesions. 
Among  the  first  to  be  mentioned  are  changes  in  the  gen- 
eral appearance  of  the  heart,  in  the  extent  of  its  displace- 
ments occasioned  by  different  positions  of  the  body,  in 
the  amplitude  of  the  movements  of  the  diaphragm  and  of 
the  costal  wall,  etc.  Among  the  second:  concomitant 
changes  in  the  lungs,  in  the  pleura  and  the  diaphragm, 
enlargements  of  the  heart  caused  by  associated  lesions, 
etc.  To  recognize  these  it  is  necessary  to  employ  all 
the  radiological  methods :  fluoroscopic  examination, 
orthodiagraphy,  teleradiography.  The  study  of  this 
subject  will  be  taken  up  as  follows  : 
*s  I.  General  data  from  radiological  examination. 
J  II.  Particular  data  relative  to  the  existence  of  peri- 
cardial adhesions. 

•/    III.     Data  relative  to  the  location  of  the  adhesions. 
•j    IV.     Comparison   of  the   results    of  percussion   and 
orthodiagraphy. 
J    V.     Clinical  observations. 

I.     GENERAL  DATA   FROM   RADIOLOGICAL   EXAMINATION 

The  preliminary  examination  of  the  shadows  of  the 
thoracic  cavity  gives  information  on  the  condition  of  the 
lungs  and  the  pleura.  This  study  demands  the  greatest 
care,  for  some  radiological  signs  may  be  common  to 
symphysis  and  to  other  cardiac  affections. 

a.  Pulmonary  field.  Certain  pulmonary  affections, 
notably  tuberculosis,  give  rise  to  respiratory  disturbances 
due  to  the  lack  of  elasticity  of  the  lung  and  are  accom- 
panied by  diminution  of  the  amplitude  of  the  diaphrag- 
matic and  rib  movements.  These  disturbances  occur  also 
in  patients  who  have  pericardial  adhesions.  But  before 
attributing  them  to  this  latter  affection  it  is  necessary 
to  make  sure  that  tuberculosis  is  not  the  cause.  That  is 
recognized  by  the  existence  of  characteristic  shadowy 
areas.     However,  the  question  of  differential  diagnosis 


AFFECTIONS  OF  THE  PERICARDIUM  107 

is  not  settled  by  the  fact  of  having  verified  the  presence 
of  pulmonary  tuberculous  lesions,  for  these  coexist  fre- 
quently with  certain  forms  of  chronic  pericarditis.  The 
object  of  radiology  here  is  only  to  determine  as  exactly 
as  possible  the  anatomical  condition  of  the  lungs  and  the 
influence  which  the  parenchymal  lesions  may  exert  on  the 
movement  of  the  diaphragm  and  the  ribs. 

In  cases  where  there  is  reason  to  think  that  certain 
functional  disturbances  are  due  to  pericardial  adhesions, 
this  opinion  is  confirmed  if  radiological  examination  of 
the  lungs  is  negative. 

b.  Pleural  shadows.  It  will  be  necessary  first  to  deter- 
mine whether  the  functional  disturbances  which  might 
suggest  pericardial  symphysis,  are  not  due  simply  to  the 
presence  of  a  pleural  effusion  which  can  always  coexist 
with  pericardial  symphysis. 

Also  pleuro-pulmonary  adhesions  may  be  mistaken  for 
pericardial  symphysis,  for  like  it  they  cause  changes  in 
the  respiratory  displacements  of  the  thoracic  organs  and 
changes  in  the  position  of  the  heart.  In  that  case  the 
radiological  findings  are  most  important;  if  they  show 
that  the  pleuras  are  free  from  adhesions,  that  will  estab- 
lish a  strong  presumption  in  favor  of  the  diagnosis  of 
cardiac  symphysis.  But  this  diagnosis  ought  not  to  be 
rejected  in  case  pleuro-pulmonary  adhesions  are  found, 
for  they  frequently  exist  with  pericardial  symphysis. 
The  diagnosis  of  this  affection  will  then  depend  on  other 
clinical  and  radiological  signs. 

c.  Mediastinal  shadows.  Examination  of  the  medias- 
tinum in  the  frontal  position  allows  the  elimination  of 
tumor  of  the  mediastinum  as  a  cause  of  functional  dis- 
turbances, for,  if  one  exists,  it  will  be  easily  recognized 
by  the  aspect  of  its  contours. 

This  done,  the  next  thing  is  to  make  radiological 
observations  of  the  anterior  mediastinum  and  the  poste- 
rior mediastinum  in  oblique  and  lateral  positions. 

In  the  normal  and  in  these   positions,   the   anterior 


168 


THE  HEART  AND  THE  AORTA 


mediastinum  appears  as  a  clear  space  between  the 
shadow  of  the  heart  and  that  of  the  sternum.  If  there 
are  adhesions  uniting  the  pericardium  with  the  sterno- 
costal wall,  this  space  is  reduced  or  completely  dis- 
appears. 


Fig.  125. 

Considerable  increase  in  the  volume  of  the  heart  in  a  patient  20  years 
of  age  with  cardiac  symphysis. 


It  is  the  same  with  the  retro-cardiac  transparent  area, 
when  there  is  posterior  mediastinitis. 

d.  Volume  of  the  heart.  It  is  hardly  necessary  to 
state  that  the  heart  shadow  should  be  determined  with 
the  greatest  care,  either  by  distant  radiography  or 
orthodiagraphy. 

In  the  cases  which  are  of  interest  here  the  heart  always 
shows  enlargement.  The  right  and  left  contours  are 
markedly  developed  (Fig.  125),  and  hypertrophy  of  the 
heart  is  sometimes  accompanied  by  a  marked  lowering 
of  the  apex.  This  can  be  due  exclusively  to  the  symphysis 
without  any  associated  valvular  lesion.  But  if  symphysis 
does  exist  at  the  same  time,  radiological  examination  will 
allow  the  usual  descriptive  characteristics  to  be  noted. 
Thus  in  the  patient  shown  in  Fig.  126  signs  of  double 


AFFECTIONS  OF  THE  PERICARDII JM 


169 


mitral  lesion  are  recognized;  salience,  above  point  G,  of 
the  pulmonary  artery,  and  of  the  auricle  compressed  by 
the  dilated  left  auricle;  increase  of  the  left  ventricular 
contour;  apex  pushed  outward,  etc. 

II.     DATA   RELATIVE   TO   THE   EXISTENCE   OF   PERICARDIAL 

ADHESIONS 

Pericardial  adhesions  show  radiological  ly  in  two  ways : 
either  they  are  directly  visible  on  the  screen  and  on  the 
plate,  because  they  are  sufficiently  dense  to  throw  a 
shadow  and  because  they  occur  in  regions  normally  trans- 


Fig.  126.     DOUBLE  MITRAL  LESION  IN  A  PATIENT  WITH 
SYMPHYSIS 


parent ;  or  they  are  not  directly  perceptible  and  are  indi- 
cated only  when  affecting  the  mobility  of  the  heart  and 
the  adjoining  organs  during  respiration  or  during 
changes  in  the  position  of  the  body. 

a.  Shadows  on  the  heart  outline  due  to  adhesions. 
These  shadow  outlines  are  best  studied  closely  on  a  radio- 
graphic plate.     They  have  been   described   by  Beck,32 

32  Beck,  Roentgen  Bay,  Diagnosis  and  Therapy,  Appleton  &  Co.,  New 
York. 


170      THE  HEART  AND  THE  AORTA 

Benedikt,33  Sturtz,34  Moritz,35  Lehmann  and  Schmoll.36 
They  are  irregular  according  to  Lehmann  and  Schmoll, 
jagged,  bordering  both  sides  of  the  heart  shadow  and 
making  its  contour  vague  and  indistinct.  These  shadows 
are  due  to  extensive  adhesions;  at  the  site  of  the  ad- 
hesions the  pulsation  of  the  heart  is  effaced.    (Fig.  127.) 

In  a  case  reported  by  Sturtz  he  says  that  "one  can 
clearly  see  adhesions  at  the  left  border  of  the  heart  and 
at  the  summit  of  the  left  diaphragm.  Starting  from  these 
areas  fine  shadows  of  adhesions  are  also  seen." 

Lehmann  and  Schmoll  state  that  it  is  necessary  to 
distinguish  these  shadows  from  those  which  are  attrib- 
uted "to  symptoms  wholly  pleural  which  have  no  direct 
bearing  on  the  pericardium  but  which  are  simply  super- 
imposed upon  the  projection  of  the  heart  shadow.  On 
the  other  hand,  the  indentations,  the  points,  the  irregu- 
larities of  the  contour  of  the  heart  due  to  pericardial 
adhesions  are  marked  in  too  clear  a  manner  to  be  ex- 
plained by  the  unreliable  evidence  against  which  Moritz 
warns." 

Besides  these  indentations  in  the  contour  of  the  heart 
the  writers  have  described  shadows  obscuring  one  or  both 
of  the  angles  formed  by  the  heart  and  the  diaphragm. 
Lehmann  and  Schmoll  have  published  radiographs  show- 
ing these  shadows  which  enabled  them  to  diagnose  peri- 
cardial diaphragmatic  adhesions. 

Beclere37  says  on  this  point:  "In  the  normal  state  the 
right  and  left  sides  of  the  cardiac  shadow  curve  in  slightly 
toward  the  median  line  before  meeting  the  contour  of 
the  shadow  of  the  diaphragm,  in  such  a  way  that  they 
limit  with  this  shadow  two  very  small  sinuses  which  may 
be   called   the   cardio-diaphragmatic   sinuses.      In   deep 

33  Benedikt,  Weiner  med.  Woch,  1900,  no.  9. 

3*  Sturtz,  Fortschritte  auf  d.  Geoiete  d.  Boentgenstrahl,  Bd.  VIII,  Heft.  5. 

35  Moritz,  Munch,  med.  Woch.,  1900,  no.  29. 

36  Lehmann  et  Schmoll,  Fortschritte  auf  d.  geo.  d.  Boentgenstrahl,  Bd. 
IX,  1905-1906,  p.  196. 

3T  Beclere,  Trait  e  de  radiologic  midicale  du  Pr.  Bouchard,  1904. 


Fig.  127. 


SHADOWS  OF  PEEICAEDIAL  ADHESIONS,  AFTER 
LEHMANN  AND  SCHMOLL 


AFFECTIONS  OF  THE  PERICARDIUM  171 

inspiration  these  two  sinuses  become  in  the  normal  larger 
and  deeper,  as  if  the  heart  separated  from  the  diaphragm. 
On  the  contrary,  if  pericardial  symphysis  exists,  the  two 
sinuses  disappear  almost  completely,  and  the  contour  of 
the  cardiac  shadow,  in  the  neighborhood  of  the  diaphrag- 
matic shadow,  invariably  keeps  the  same  form  at  the  end 
of  expiration  and  inspiration." 

When  adhesions  are  present  on  the  contour  of  the  heart 
the  shadows  are  seen  on  the  screen  and  especially  on  the 
plates;  on  this  point  our  observations  confirm  those 
already  cited.  However,  the  presence  of  these  shadows 
is  far  from  being  constant,  and  we  have  rarely  found 
them.  As  to  the  costal-diaphragmatic  or  cardio-dia- 
phragmatic  sinuses  being  obscured,  to  which  Lehmann 
and  Schmoll  attribute  great  importance  as  a  sign  of 
adhesions,  it  has  not,  in  our  opinion,  that  significance 
except  with  certain  reservations. 

In  the  first  place  it  may  happen  that  the  increase  in 
density  of  the  pericardial  folds,  at  the  point  of  their  left 
phrenic  insertion,  may  produce  an  obscurity  which  is 
purely  physiological.  The  disappearance  of  the  cardio- 
hepatic  sinus  may  be  due  to  a  similar  thickening  of  the 
folds  of  the  pericardium,  or  to  an  abnormal  distention  of 
the  inferior  vena  cava,  or  even  to  an  inflammation  or 
dilatation  of  the  right  ventricle.  Finally,  it  sometimes 
happens  that  the  left  cardio-diaphragmatic  sinus  is 
covered  by  the  hypertrophied  heart. 

Now,  it  is  rather  difficult  to  be  sure  that  these  condi- 
tions do  not  intervene  in  the  obscuring  of  the  cardio- 
diaphragmatic  sinuses,  which  makes  the  value  of  this 
sign  somewhat  uncertain.  The  radiographic  plates  which 
ought  to  be  useful  are  technically  often  defective,  how- 
ever carefully  they  are  taken. 

On  the  contrary,  the  signs  about  to  be  studied  are  in 
more  direct  relation  to  the  adhesions  at  the  apex  of  the 
heart. 

b.     Modifications  of  displacements  of  the  shadoiv  of 


172      THE  HEART  AND  THE  AORTA 

the  heart  and  of  the  diaphragm.  Displacements  of  the 
heart  observed  in  the  physiological  state  are  caused 
either  by  changes  in  the  position  of  the  body  or  by  respi- 
ration which  modify  the  intra-thoracic  pressure.  These 
displacements  are  naturally  more  or  less  reduced  or  even 
rendered  impossible  if  the  heart  is  attached  to  the  thorax 
or  to  the  neighboring  organs  by  adhesions.  It  is  im- 
portant therefore  to  make  a  detailed  study  of  them. 
These  displacements  affect  either  the  heart  as  a  whole 
or  more  especially  its  apex. 

1.  Apex  of  the  Heaet.  The  apex  of  the  heart,  nor- 
mally mobile,  is  displaced  outward  from  2  to  2.5  cm. 
when  the  body  is  inclined  toward  the  left;  moreover, 
it  descends  and  rises  during  inspiration.  It  is  the 
amplitude  of  these  displacements,  the  lateral  displace- 
ment and  the  vertical  displacement  that  must  be  observed 
in  order  to  know  the  degree  of  mobility  of  the  apex. 

If  the  lateral  displacement  is  abolished,  the  contours 
of  the  cardiac  shadow,  traced  on  the  skin  of  the  patient, 
first  in  the  vertical  position,  then  in  the  left  inclination, 
are  exactly  superimposed.  Sometimes  the  immobility 
both  of  the  ventricular  contour  and  of  the  apex  is  com- 
plete ;  or,  the  apex  being  very  clearly  fixed,  the  ventricular 
contour  alone  is  displaced  slightly  outward.  Then,  espe- 
cially if  the  heart  is  large,  the  left  ventricle  is  seen  to  fill 
markedly  during  the  change  of  position  until  it  pushes 
against  the  thoracic  wall  (Fig.  128),  whereas  the  position 
of  the  apex  remains  unchanged. 

When  the  lateral  displacement  only  is  reduced,  the 
successive  contours  which  indicate  the  apex  are  very 
close  together.  This  sign  is  found  in  cases  where  the 
apical  adhesions  are  loose;  but  adhesions  of  the  right 
side  of  the  heart  may  produce  the  same  effect. 

The  mobility  of  the  apex  does  not  exclude  the  diagnosis 

of  pericardial  adhesions  nor  does  its  fixity  establish  the 

diagnosis.    In  fact,  we  have  always  found  the  apex  fixed 

v    in  cases  of  adhesions,  but,  theoretically,  it  is  conceivable 


AFFECTIONS  OF  THE  PERICARDIUM 


173 


that  adhesions,  confined  to  the  base  of  the  heart,  should 
leave  the  apex  mobile.  On  the  other  hand,  it  is  not  con- 
ceivable that  other  causes  than  adhesions  should  be 
capable  of  completely  immobilizing  the  apex  of  the  heart. 
In  practice  a  considerable  cardiac  enlargement  may  have 
the  effect  of  pushing  it  against  the  thoracic  wall  and  on 
the  diaphragm  which  becomes  depressed  and  thus  offers 
complete  resistance  to  displacement  of  the  apex.  The 
result  will  be  an  error  in  interpretation  which  will  there- 
fore lead  to  a  wrong  diagnosis. 


Fig.  128.  IMMOBILITY  OF  THE  APEX  WITH  MOVEMENT  OF  THE 
LEFT  SIDE  TOWAED  THE  EXTERNAL  THOEACIC  WALL  DUR- 
ING INCLINATION  OF  THE  BODY  TO  THE  LEFT 

Dotted  lines,  contour  of  left  side  during  inclination.     Apex  fixed  at  level 
of  the  cross. 


Vertical  displacement  of  the  apex  is  observed  during 
respiratory  movements.  During  deep  inspiration  the 
apex  is  lowered  and  moves  slightly  inward ;  during  deep 
expiration  the  apex  is  raised  and  moves  outward.  In 
cardiac  symphysis  these  displacements  are  usually 
diminished  or  abolished. 

The  following  conditions  may  occur : 

(a)   The  adhesions  fix  the  apex  to  the  thoracic  wall. 


174      THE  HEART  AND  THE  AORTA 

The  apex  is  then  not  associated  with  the  movements  of 
the  diaphragm  but  maintains  constant  relations  with  the 
thorax. 

(b)  Adhesions  fix  the  heart  to  the  thoracic  wall  and  to 
the  diaphragm.  The  vertical  displacements  of  the  apex 
are  much  diminished  or  disappear,  and  the  movement 
of  the  left  diaphragm  is  much  reduced,  at  least  in  its 
medial  portion. 

(c)  Adhesions  exist  only  between  the  apex  and  left 
diaphragm.     In  this  case  the  lateral  displacements  are 

^  abolished  and  the  vertical  movements  remain.  The  apex, 
fixed  to  the  diaphragm,  lowers  and  rises  during  inspira- 
tion and  expiration.  This  sign  should  be  accepted  only 
with  reservation  as  a  sign  of  local  symphysis,  when  the 
heart  is  enlarged.  It  may  be  added  that  absence  of  verti- 
cal displacements  does  not  always  mean  that  the  apex 
is  adherent,  for  solid  adhesions  of  the  anterior  surface 
may  make  the  whole  organ  immobile. 

2.  Displacements  of  the  Heakt  Outlines.  Briefly, 
the  heart,  during  respiratory  movements,  undergoes 
marked  displacements  which  not  only  lower  it  and  elevate 
it  as  a  whole  in  the  thoracic  cavity  but  which  result  in 
deformations  of  its  contours  :  in  deep  inspiration  the  car- 
diac shadow  is  elongated  and  contracted,  whereas  in  forced 
expiration  it  broadens  and  is  enlarged  from  right  to  left. 

All  these  modifications  may  be  completely  transformed 
if  adhesions  exist.  The  respiratory  displacements  are 
sometimes  less  extended  on  one  side,  either  to  the  left 
or  right  (Fig.  129) ;  sometimes  a  small  part  of  one  of 
the  contours  is  less  mobile ;  at  other  times  one  of  the  sides 
remains  fixed  while  the  other  is  displaced  (Fig.  130) ; 
and,  finally,  the  entire  contour  of  the  heart  is  sometimes 
displaced,  excepting  the  apex  which  remains  immobile 
(Fig.  131). 

These  variations  are  explained  by  the  different  posi- 
tions of  the  adhesions. 

If,  for  instance,  the  left  side  only  is  attached  to  the 


AFFECTIONS  OF  THE  PERICARDIUM 


175 


costal  wall  to  a  slight  extent,  it  can  be  assumed  that  the 
heart  does  not  follow  the  diaphragm  in  its  inspiratory 
movement,  and  since  the  rest  of  the  organ  is  free,  the 
right  side  retains  its  normal  movements. 

When  the  adhesions  of  the  left  side  or  of  the  anterior 
surface  of  the  heart  are  extensive  and  very  adherent,  the 
contours  of  the  heart  are  absolutely  immobile  and  the 
lines  which  mark  them  on  the  screen  successively  during 
inspiration  and  expiration  are  exactly  superimposed. 

It  may  happen  in  certain  cases  that  a  rather  para- 
doxical phenomenon  is  found,  namely,  elevation  of  the 
contour  of  the  heart  during  deep  inspiration,  the  oppo- 
site of  what  happens  normally.  This  is  explained  by  the 
close  adhesion  of  the  organ  to  the  sterno-costal  plastron ; 
the  heart  consequently  follows  the  forward  and  upward 
movements  of  the  sternum  during  inspiration.  For  this 
to  occur  it  is  necessary  that  the  lower  region  of  the  heart 
be  free  from  adhesions  and  that  the  bottom  of  the  peri- 
cardial sac  be  sufficiently  extensible  so  that  the  heart  is 
not  pulled  during  the  lowering  of  the  diaphragm. 


Fig.  129 


Fig.  130 


Fig.  129.     M.,  16  YEAES  OF  AGE 

The  respiratory  displacements  of  the  heart  are  much  reduced,  especially 
on  the  left. 


Fig.  130.     LEON  P.,  7%  YEAES  OF  AGE 

Immobility  of  the  left  contour.     Diminished  mobility  of  the  right  con- 
tour during  respiratory  movements. 


176 


THE  HEART  AND  THE  AORTA 


Finally,  if  the  lower  part  of  the  heart,  the  diaphragm, 
and  the  thoracic  wall  are  closely  united  on  one  side,  there 
will  be  no  displacements  in  this  region,  but  fairly  ample 
ones  on  the  other  side. 


Fig.  131.     TH.,  20  YEAES  OF  AGE 

The  contour  in  dotted  lines  shows  that  in  deep  inspiration  the  heart  is 
lowered,  except  the  apex. 


3.  Movements  of  the  Diapheagm.  The  pericardium 
is  inserted  in  the  center  of  the  diaphragm,  the  two  halves 
of  which,  the  right  and  left,  have  in  the  normal  almost 
synchronous  downward  and  upward  movements. 

The  right  dome  of  the  diaphragm  is  a  little  more  ele- 
vated than  the  left  because  of  the  position  of  the  liver. 
The  movements  are,  on  the  contrary,  generally  somewhat 
more  extended  on  the  right.  According  to  Lange38  they 
should  be  3  cm.  on  the  right,  2.8  cm.  on  the  left  in  deep 
inspiration.  During  quiet  inspiration  they  should  be  1.25 
cm.  on  the  right,  and  1.2  cm.  on  the  left.  Taking  succes- 
sively the  orthodiagraph^  tracings  in  deep  inspiration 
and  expiration  we  have  found  higher  figures  for  the  dis- 
tance between  the  centers  of  the  domes  of  the  diaphragm, 
3.5  cm.  to  4.5  cm.  on  the  right,  3  cm.  to  4  cm.  on  the  left, 

ss  Sidney  Lange,  The  Eelations  of  the  Diaphragm  as  Eevealed  by  the 
Eoentgen  Eay,  Journ.  of  Amer.  Med.  Assoc,  Feb.,  1908. 


AFFECTIONS  OF  THE  PERICARDIUM  177 

in  man.  In  woman  the  amplitude  of  these  movements  is 
less. 

If  for  some  pathological  reason  one  of  the  diaphragms 
is  rendered  immobile  or  its  movements  merely  reduced, 
the  other  diaphragm  may  keep  its  normal  degree  of 
excursion  (Figs.  129,  130,  131,  132). 

When  there  is  no  pathological  disturbance  in  the  lungs, 
the  pleurce,  and  the  liver  to  explain  the  diminutions  of  the 
diaphragmatic  movements,  the  modifications  observed 
are  attributable  to  adhesions  between  the  heart,  the  peri- 
cardium and  the  diaphragm.  The  mobility  of  the  phrenic 
muscle  is  only  slightly  diminished  by  these  adhesions. 
To  have  it  reduced  or  abolished,  it  is  necessary  that  the 
pericardium  and  the  heart  adhere  on  the  other  side,  either 
to  the  thoracic  wall  or  to  the  organs  of  the  posterior 
mediastinum. 

When  a  patient  is  examined,  one  should  not  be  content 
simply  to  mark  with  two  superimposed  points  the  maxi- 
mal distance  of  the  excursion  of  the  diaphragm.  All  the 
outlines  of  the  contours  of  the  phrenic  muscle  by  the 


Fig.  132.  THE  EXPANSION  OF  THE  DIAPHEAGM  IS  MUCH  EE- 
DUCED  ON  THE  LEFT  IN  THE  INNEE  THIED,  A  LITTLE 
FULLEE  IN  THE  OUTEE  TWO-THIEDS,  NOEMAL  ON  THE 
EIGHT. 


178 


THE  HEART  AND  THE  AORTA 


orthodiagraph^  method  give,  in  certain  cases,  interest- 
ing information :  the  movement  of  the  two  diaphragms  is 
sometimes  immobilized  in  part,  the  inner  portion  for 
example,  while  the  outer  or  costal  portion  shows  decided 
movements  up  and  down  (Fig.  132). 

It  is  often  interesting  to  study  the  movements  of  the 
diaphragm  in  vertical  position  and  in  dorsal  recum- 
bency.    The  normal  forced  inspiration  lowers  the  dia- 


Fig.  133  Fig.  134 

Fig.  133.     GERMAINE  D.,  liy2  YEAES  OF  AGE 
Diminution  of  the  excursion  of  the  diaphragm  in  vertical  position. 

Fig.  134.     SAME  CASE 

Equally  marked  diminution  of  the  excursion  of  the  diaphragm  in  recum- 
bency. 

phragm  and  the  heart  much  less  in  the  vertical  position 
than  in  recumbency.  If  the  heart  is  large,  as  is  generally 
the  case  in  cardiac  symphysis,  the  organ,  by  its  own 
weight,  depresses  the  diaphragm,  especially  on  the  left, 
and  obstructs  its  movements.  In  order  to  make  sure  that 
the  decrease  of  excursion  is  not  due  solely  to  this  cause, 
a  second  observation  in  recumbency  should  be  made,  the 
position  in  which  the  weight  of  the  heart  has  no  effect.  If 
as  marked  a  reduction  of  the  movements  is  found,  then 
the  hypothesis  that  adhesions  reduce  the  excursion  of  the 
diaphragm  (Figs.  133  and  134)  can  be  considered. 


AFFECTIONS  OF  THE  PERICARDIUM 


179 


By  examining  the  movement  of  the  diaphragm,  the 
mechanism  of  a  sign  described  by  Broadbent,39  which  con- 
sists in  the  systolic  retraction  of  the  posterior  thoracic 
wall  at  the  level  of  the  lower  ribs,  can  also  be  explained. 
It  can  be  done  by  fixing  an  opaque  index  over  the  region 


Fig.  135.    PATIENT  EXAMINED  IN  SLIGHTLY  OBLIQUE  POSITION 
(EIGHT  ANTERIOR) 

On  the  left  thoracic  contour  the  shadow  of  the  lead  index  is  shown  situated 
in  the  zone  in  which  appears  Broadbent 's  sign.  In  dotted  lines,  the  contour 
of  the  diaphragm  stretched  at  each  systole. 

of  the  maximum  movement  of  retraction ;  then  it  is  seen, 
if  the  patient  is  placed  obliquely,  that  this  index  corre- 
sponds exactly  to  the  posterior  costal  insertions  of  the 
diaphragm  and  that  the  muscle  is  under  tension  at  each 
cardiac  contraction  (Fig.  135).  It  is  necessary,  then,  to 
obtain  Broadbent 's  sign,  that  the  heart  and  the  pericar- 
dium should  adhere  not  only  to  the  diaphragm  but  also 
to  the  anterior  thoracic  wall.  However,  this  sign  is  of 
no  pathognomonic  value.  It  is  found  independent  of  car- 
diac symphysis  when  pleural  adhesions  diminish  the  dia- 
phragmatic movement  and  when  the  heart,  increased  in 

39  Broadbent,  Diseases  of  the  Heart,  London,  1897. 


180 


THE  HEART  AND  THE  AORTA 


y  volume  and  strongly  depressing  the  diaphragm,  transmits 
its  pulsations  to  it. 

4.     Outline  of  the  Heart.    By  placing  the  patient  in 
the  lateral  position,  the  anterior  outline  of  the  heart  can 


Fig.  136.     M.,  25  YEAES  OF  AGE 

Symphysis  of  the  heart  and  the  anterior  wall.  In  right  lateral  position, 
the  anterior  clear  space  disappears  in  its  lower  half  during  forced  inspira- 
tion. 


be  traced  behind  the  sternal  border.  In  the  normal,  they 
are  separated  by  a  clear  triangular  zone  which  is  very 
wide  at  the  level  of  the  vessels  and  grows  narrower  as  it 
approaches  the  shadow  of  the  diaphragm.  This  clear 
zone  grows  wider  and  becomes  clearer  during  deep 
inspiration. 

If  the  heart  is  attached  to  the  anterior  thoracic  wall,  it 
becomes  impossible  to  find  the  anterior  clear  space,  even 
with  forced  inspiration  (Fig.  136). 

This  sign,  in  spite  of  its  value,  is  not,  however,  pathog- 
nomonic. It  is  found  in  cases  in  which  there  are  no 
adhesions,  notably  when  the  heart  is  considerably  hyper- 
trophied.  On  the  contrary,  if  the  retro-sternal  clear 
space  keeps  its  normal  transparency,  it  is  safe  to  say  that 
there  is  no  adhesion  between  the  heart  and  sternal  border, 
on  condition,  however,  that  the  radioscopic  examination 
has  been  made  exactly  at  an  angle  of  90  degrees. 


AFFECTIONS  OF  THE  PERICARDIUM         181 

c.  Respiratory  outline.  The  study  of  the  respiratory 
outline  of  the  thorax,  that  is,  the  movements  of  projec- 
tion and  retraction  of  the  sternum,  observed  with  the 
patient  in  the  lateral  position,  does  not  belong  exclusively 
to  the  domain  of  radioscopy.  Wenckebach  has  made  use 
of  photography  to  establish  the  details.  But  observation 
by  orthodiagraphy  is  easier  and  quicker,  and  we  usually 
use  this  method. 

In  the  normal  the  two  lines  which  indicate  the  respira- 
tory outline  in  deep  inspiration  and  expiration  are  equi- 
distant in  the  greater  part  of  their  length ;  they  unite  at 
the  level  of  the  abdominal  region  (Fig.  137). 

This  respiratory  outline  should  always,  according  to 
Wenckebach,  be  markedly  modified  in  case  of  cardiac 
symphysis.  The  sternum  should  then  maintain,  in  its 
lower  third,  such  a  degree  of  immobility  that  the  two 
lines  which  represent  its  displacement  should  cross  at  a 
fixed  point  (Fig.  138). 

The  crossing  of  the  two  lines,  otherwise  called  the 
"crossed  outline"  of  Wenckebach,  is,  to  be  sure,  very 
rare.    We  have  met  it  only  in  cases  of  adhesions  of  the 


I 


Fig.  137.     NORMAL  RESPIRATORY  OUTLINE 
Black  line,  deep  expiration;   dotted  line,  deep  inspiration. 


182      THE  HEART  AND  THE  AORTA 

base  of  the  heart.  Less  value  should  be  attached  to  the 
simple  diminution  of  the  divergency  of  the  two  outlines 
(Fig.  139),  which  is  merely  a  suggestive  indication.  On 
the  contrary,  its  absence  should  not  cause  the  rejection 
of  the  diagnosis  of  cardiac  symphysis,  as  has  been  noted, 
when  pericardial  adhesions  were  present. 


Fig.    138.      CROSSED    RESPIRATORY    OUTLINE,    ACCORDING    TO 

WENCKEBACH 


1/ 


K 


Fig.  139.     RESPIRATORY  OUTLINE  OF  SLIGHT  EXCURSION 


AFFECTIONS  OF  THE  PERICARDII^  183 

III.     PARTICULAR   DATA   RELATIVE   TO  THE   SITE   OF 
ADHESIONS 

In  this  study,  adhesions  will  not  be  considered  which 
unite  the  two  folds  of  the  pericardium,  the  heart  remain- 
ing mobile  in  the  united  sac.  These  adhesions  are  not 
accompanied  naturally  by  any  fluoroscopic  modification. 
Besides,  they  have  not  much  importance ;  they  do  not  give 
rise  to  functional  disturbances  and  Laennec  stated  that 
this  condition  did  not  constitute  a  real  disease  of  the 
heart.  Only  cases  which  are  clinically  important  wTill  be 
considered  in  which  the  heart  united  to  its  pericardial  sac 
has  consequently  contracted  adhesions  with  the  thoracic 
wall,  mediastinum  and  diaphragm. 

1.  Adhesions  of  the  Base  of  the  Heart.  These  can 
be  demonstrated  by  the  following  signs : 

a.  Irregular  notched  shadows  on  the  upper  contour  of 
the  heart.  These  shadows  sometimes  occupy  a  large  sur- 
face and  extend  round  the  great  vessels  or  toward  the 
thoracic  wall.  Their  visibility  is  not  constant  and  de- 
pends on  their  development  outside  the  stern o-vertebral 
and  cardiac  shadow. 

b.  Absence  of  lateral  displacements  of  the  base  of  the 
heart.  In  the  left  lateral  inclination,  the  displacements 
of  the  organ,  which  are  rather  slight  in  the  normal,  are 
absolutely  non-existent. 

c.  Diminution  or  abolition  of  the  respiratory  displace- 
ments of  the  heart  in  the  upper  third  of  its  projection. 
During  deep  inspiration,  for  example,  the  upper  contour 
of  the  heart  remains  immobile,  while  toward  the  apex,  the 
shadow  of  the  organ  is  elongated  and  consequently 
lowered. 

d.  Slight  modifications  of  the  mobility  of  the  dia- 
phragm. The  excursion  of  the  diaphragm  is  slightly 
diminished  during  deep  respiration,  as  a  result  of  the 
fixity  of  the  base  of  the  heart. 

2.  Adhesions  of  the  Apex. 

a.     Presence  of  shadows  of  adhesions.    If  the  heart  is 


184      THE  HEART  AND  THE  AORTA 

not  too  large,  we  see  the  denticulations  made  by  the 
shadow  of  the  adhesions  projected  all  ronnd  the  apex; 
they  unite  with  the  diaphragm  and  obscure  the  left 
cardio-diaphragmatic  sinus. 

,/  b.  Immobility  of  the  apex.  The  immobility  of  the 
apex  is  absolute  in  the  lateral  direction  and  almost  com- 
plete in  the  vertical. 

In  order  to  affirm  that  adhesions  are  localized  only  at 
the  apex,  it  is  necessary  to  prove  the  persistence  of  dis- 
placements of  the  left  side,  to  the  exclusion  of  the  apex. 

3.  Adhesions  in  the  Diaphkagmatic  Region,  a.  The 
adhesions  exist  only  between  the  lower  edge  of  the  heart, 
the  pericardium  and  the  diaphragm.  They  extend  either 
to  both  diaphragms  or  to  only  one.  In  the  first  case,  the 
movements  of  the  two  diaphragms  are  appreciably  dimin- 
ished, especially  during  deep  inspiration  and  in  the  inner 
portion  of  their  contour.  In  the  second  case,  the  difficul- 
ties of  diaphragmatic  excursion  appear  only  on  one  side. 

b.  In  most  of  the  adhesions  above,  the  pericardium  is 
in  symphysis  with  the  thoracic  wall.  The  diaphragmatic 
movements  are  then  greatly  reduced,  sometimes  abolished 
in  the  greater  part  of  their  contour. 

The  value  of  these  observations  is  relative.  Their 
bearing  on  the  symphysis  will  be  established  only  if  no 
thoracic  lesion  exists  (such  as  simple  pleuro-pulmonary 
adhesions)  capable  of  reducing  the  field  of  excursion  of 
the  diaphragm. 

4.  Adhesions  to  the  Anteeioe  Thoracic  Wall.  When 
large  adhesions  fix  the  anterior  surface  of  the  heart  to  the 
thoracic  wall,  the  movements  due  to  the  displacement  of 
the  body  and  the  respiratory  movements  of  the  organ  are 
much  diminished,  or  abolished,  or  occasion  the  paradoxi- 
cal phenomenon  of  inspiratory  raising  of  the  heart.  The 
fixity  of  the  organ  hinders  the  excursion  of  the  diaphragm 

f  whose  movements  are  reduced.  In  lateral  position,  the 
retro-sternal  clear  space  remains  dark  during  forced 
inspiration. 


AFFECTIONS  OF  THE  PERICARDIUM  185 

5.  Posterior  Mediastinitis.  Posterior  mediastinitis 
has  only  a  secondary  interest,  but  as  it  may  complicate 
cardiac  symphysis,  it  is  necessary  to  know  whether  it 
exists  or  not.  For  this  radioscopy  in  the  oblique  position 
is  used.  In  this  position,  as  Lambour40  reminds  us,  fol- 
lowing Holzknecht,  von  Dehn,  and  Radonicic,  mediasti- 
nal involvements  manifest  themselves  by  shadows  which 
obscure  the  retro-cardiac  clear  area. 

6.  Complicated  Cases.  In  order  to  present  as  precise 
a  description  as  possible  of  the  findings  of  radiology  in 
cases  of  pericardial  adhesions,  they  have  to  be  schema- 
tized. It  is  evident  that  in  practice  more  complicated  sit- 
uations are  met  with,  for  adhesions  may  exist  at  the  same 
time  in  different  regions.  The  signs  which  have  just  been 
described  will  then  be  found  associated,  but  the  diagnosis 
will  not  on  that  account  be  rendered  more  difficult.  It  will 
demand  simply  more  minute  attention.  It  may  be 
added,  however,  that  more  frequently  than  is  thought, 
the  adhesions  affect  in  their  disposition  one  or  the  other 
of  the  areas  which  have  been  described. 

IV.     COMPARISON    OF    THE    RESULTS    OF    PERCUSSION    AND 
ORTHODIAGRAPHY 

Radioscopy  and  percussion  give  some  information 
common  to  both  and  other  findings  which  are  special  to 
each  method.  So  these  two  methods,  far  from  being 
mutually  exclusive,  assist  each  other  and  thus  increase 
the  means  of  diagnosis. 

Common  Findings.  Orthodiagraphic  tracings  and  the 
tracings  of  percussion  taken  in  the  frontal  or  direct  ante- 
rior position  can  most  often  be  superimposed.  They  both 
give  the  measure  of  the  heart  area,  its  degree  of  hyper- 
trophy or  of  dilatation.  However,  orthodiagraphy  is 
more  accurate  than  percussion  in  outlining  exactly  the 
contour  of  the  right  side.  The  same  is  also  true  for  the 
position  of  the  apex  and  its  degree  of  mobility. 

Findings  Peculiar  to  Radiology.    These  concern  more 

40  P.  Lambour,  These  de  Paris,  191]. 


\S 


J 


186      THE  HEART  AND  THE  AORTA 

especially  the  shadows  of  adhesions  on  the  contours  of 
the  heart,  the  respiratory  displacements  of  the  organ,  the 
modifications  of  the  diaphragmatic  movements,  the  ob- 
scuring of  the  anterior  and  posterior  mediastinum. 

Findings  Peculiae  to  Percussion.  The  most  impor- 
tant is  that  which  establishes  the  relation  of  absolute  to 
partial  dullness.  It  is  known  that  very  often  in  cardiac 
symphysis,  the  surface  of  complete  or  absolute  dullness  is 
considerable.  The  nature  of  this  clinical  sign,  the  value 
of  which  has  always  appeared  to  us  important,  is  not  here 
interpreted.  It  need  only  be  said  that  no  radiological  sign 
corresponds  to  it :  the  shadow  of  the  heart  projected  on 
the  screen  or  on  the  plate  corresponds  only  to  the  surface 
of  relative  dullness. 

Another  sign  obtained  in  certain  cases  by  percussion 
consists  in  the  invariability  of  the  line  of  cardiac  dullness 
during  inspiration  and  expiration.  This  is  explained  by 
an  adhesion  of  the  heart  to  the  sterno-costal  wall,  such  an 
adhesion  that  pulmonary  tissue  no  longer  lies  between  the 
edge  of  the  heart  and  the  wall  during  profound  inspira- 
tion, which  suppresses  all  difference  of  sound  on  percus- 
sion. 

It  is  evident  that  this  sign  relates  to  percussion  only 
because  it  consists  in  tone  modifications.  But  it  can  al- 
ways be  rectified  by  examination  on  the  screen,  which 
sometimes  will  show  an  absolute  immobility  of  the  con- 
tours of  the  heart  which  percussion  might  have  missed. 

It  should  be  noted,  however,  that  Ceyka  has  doubted 
the  value  of  this  sign  and  according  to  him  immobility  of 
the  pulmonary  outlines  might  cause  it  as  well  as  pericar- 
dial symphysis. 

V.     CLINICAL  EXAMPLES 

The  following  cases  "are  reported  to  demonstrate  the 
value  of  radiological  examination  in  the  diagnosis  and 
position  of  pericardial  adhesions. 

The  first  is  a  case  of  symphysis  of  the  apex  in  which 
the  radiological  signs  confirmed  the  clinical  diagnosis. 


AFFECTIONS  OF  THE  PERICARDIUM  187 

Th.  L.,  twenty-two  years  of  age,  subject  to  rheumatic 
attacks  since  five  years  of  age,  has  been  in  the  hospital 
frequently.  He  entered  our  service  January  7, 1909,  with 
marked  dyspnoea  associated  with  painful  palpitations. 

Clinical  examination.  Apex  in  the  fifth  intercostal 
space  pushed  slightly  outward.  Apparently  displaced 
half  a  centimeter  when  the  patient  changed  from  the 
dorsal  to  the  left  lateral  recumbency. 

Seesaw  movement  of  the  wall  with  systolic  elevation 
of  the  apex  and  systolic  retraction  of  the  wall  in  the 
fourth  intercostal  space  two  fingerbreadths  above  and 
inward  from  the  nipple  line. 

Broadbent's  sign  at  the  left. 

The  outline  of  the  heart  on  percussion  gives :  area  of 
relative  dullness  increased,  measuring  120.65  square 
centimeters ;  increase  of  absolute  dullness. 

Auscultation:  diastolic  murmur  at  the  aortic  area 
transmitted  along  the  right  border  of  the  sternum; 
double  crural  murmur. 

Pulse  regular,  bounding,  54  pulsations  a  minute. 

Systolic  tension,  16-17  (sphygmo-signal). 

Liver  slightly  enlarged,  overlapping  the  false  ribs  two 
fingerbreadths. 

Clinical  diagnosis :  aortic  insufficiency,  pericardial 
symphysis. 

Radiological  examination : 

Dimensions  of  the  heart.  Area  of  projection,  127 
square  centimeters.  Left  side,  15.6  cm.  long;  right  side, 
8.3  cm.  Longitudinal  diameter,  16.8  cm. ;  horizontal 
diameter,  15.3  cm.  Apex  rounded,  lowered,  pushed  out- 
ward. Marked  hypertrophy  of  the  left  ventricle  (Fig. 
140). 

Respiratory  displacements  of  the  heart.  During  deep 
inspiration  and  expiration,  the  displacements  of  the  heart 
contours  are  very  marked ;  they  are  normal  on  the  right, 
but  on  the  left  side,  especially  the  middle  part,  they  are 


188 


THE  HEART  AND  THE  AORTA 


very  great,  whereas  there  are  no  displacements  at  the 
level  of  the  apex  (Fig.  141). 


Fig.  140.    TH.  L.    SYMPHYSIS  OF  THE  APEX 
Aortic  insufficiency.     Hypertrophy  of  the  left  ventricle. 

Apex  of  the  heart.  It  is  immobile  during  left  lateral 
inclination.  When  the  patient  is  inclined  far  to  the  left, 
the  contour  of  the  shadow  of  the  left  ventricle,  above  the 
apex,  approaches  the  external  thoracic  wall. 

Movements  of  the  diaphragm.  During  deep  inspira- 
tion, the  right  diaphragm  is  depressed  4.5  cm.,  whereas 
the  left  has  a  reduced  displacement  of  about  0.5  cm.  (Fig. 
141). 

Outline  of  the  heart.  In  lateral  position  at  90  degrees, 
the  retro-sternal  clear  space  is  not  visible  in  its  lower 
third,  even  during  forced  inspiration. 

Respiratory  outline.    Form  normal,  ample. 

No  abnormal  shadows  on  the  heart  contour,  nor  in  the 
pulmonary  field. 

Conclusion.  Signs  of  adhesions  of  the  heart  apex.  Its 
immobility  and  the  greatly  reduced  movements  of  the  left 
diaphragm  can  be  explained  only  by  the  fixation  of  the 
apex  to  the  anterior  thoracic  wall  on  one  side  and  to  the 
left  diaphragm  on  the  other. 

In  another  case,  the  adhesions  were  on  the  anterior  and 
superior  surfaces  of  the  heart. 


AFFECTIONS  OF  THE  PERICARDII  \\I 


189 


H.,  15  years  of  age,  entered  la  salle  Lorain  in  June, 
1911,  for  dyspnoea.  No  rheumatism  in  his  history.  Ob- 
jective examination  shows  the  apex  beat  in  the  sixth  inter- 
costal space  in  the  nipple  line.  It  is  immobile  when  the 
patient  passes  from  dorsal  to  lateral  recumbency.  Aus- 
cultation gives  a  systolic  murmur  of  mitral  insufficiency, 
accentuation  of  the  second  pulmonic  sound.  Broadbent's 
sign  on  the  left. 

Orthodiagraphy  gives  the  following  (Fig.  142)  : 

(a)  Absolute  immobility  of  the  apex  in  lateral  dis- 
placements; slight  mobility  in  vertical  displacements. 

(b)  Very  marked  diminution  of  the  res  juratory  dis- 
placements of  the  left  side,  which  presents  in  its  upper 
third,  to  a  slight  degree,  the  paradoxical  sign  of  inspira- 
tory elevation  in  the  vertical  position.  On  the  right,  the 
respiratory  displacements  of  the  heart  are  maintained. 

(c)  Diminution  of  the  excursion  of  the  diaphragm, 
both  sides,  especially  left. 

(d)  Cardiac  area  moderately  increased:  longitudinal 
diameter,  15  cm. ;  horizontal  diameter,  15.5  cm. 


Fig.  141.    TH.  L.    IMMOBILITY  OF  THE  APEX 

Bespiratory  displacements  of  the  right  and  left  contours  of  the  heart 
of  normal  size,  excluding  the  apex.  Marked  diminution  of  left  diaphrag- 
matic  movement. 


190 


THE  HEART  AND  THE  AORTA 


(e)  Respiratory  outline  reduced. 

Conclusion.  The  clinical  signs  warrant  the  diagnosis 
of  cardiac  symphysis.  Radiological  examination  local- 
izes the  adhesions  on  the  anterior  surface  of  the  heart 
because  of  modifications  in  the  respiratory  displacements 
of  the  left  side  and  the  lateral  immobility  of  the  apex. 

These  cases  will  suffice  to  illustrate  the  method  fol- 
lowed in  examining  by  fluoroscopy  patients  supposed  to 
have  pericardial  adhesions. 

There  are  cases,  however,  in  which  no  positive  diagno- 
sis can  be  made.  Ordinarily,  these  are  young  patients 
with  valvular  cardiopathies,  most  often  aortic,  and  at 
the  same  time  with  considerable  cardiac  hypertrophy 
which,  in  a  degree,  immobilizes  the  heart.  In  these  cases, 
the  radiological  and  the  clinical  signs  may  easily  be  mis- 
taken for  symphysis.  In  a  case  like  this  which  we  exam- 
ined (Fig.  143),  there  was  a  clear  rolling  movement  on 
the  surface  of  the  heart,  almost  complete  immobility  of 
the  apex,  systolic  retraction  of  the  last  intercostal  spaces 
posteriorly  and  to  the  left  (Broadbent's  sign) ;  in  addi- 
tion to  these  signs  there  was  a  slight  decrease  of  the 
respiratory  displacements  of  the  heart  and  a  very  marked 


Tig.  142.    L.  H.,  15  YEAES  OF  AGE. 

Adhesions   of  anterior  surface  of  heart.     Black  lines,  deep   expiration. 
Dotted  line,  deep  inspiration. 


AFFECTIONS  OF  THE  PERICARDIUM 


191 


diminution  of  the  diaphragmatic  movement  on  the  left. 
This  combination  of  symptoms  led  to  the  assumption  that 
pericardial  adhesions  existed.  Autopsy,  however,  showed 
that  there  were  none  and  also  explained  the  error  in 


Fig.  143.    V.,  20  YEAES  OF  AGE.    COB  BOVINUM 
Pleuro-pulmonary  adhesions.    No  cardiac  symphysis. 


interpretation.  The  weight  of  the  greatly  enlarged  heart 
pressed  on  the  diaphragm  which  it  rendered  immobile; 
its  mass  was  such  that  it  prevented  respiration  affecting 
the  normal  heart  changes.  Finally,  contact  of  the  ventri- 
cle with  the  wall  over  a  large  area  prevented  the  lung 
from  slipping  under  the  sterno-costal  plastron  at  the 
moment  of  systolic  retraction  when  separation  occurs  be- 
tween heart  and  thoracic  wall,  and  this,  because  the  tho- 
racic wall  was  flexible  (young  patient),  accounted  for  the 
precordial  retraction  and  the  rolling  movement  found 
during  life.  The  retraction  of  the  intercostal  spaces  was 
due  to  pleuro-diaphragmatic  adhesions,  results  of  pleu- 
risy which  the  patient  had  previously  had. 

It  is  evident  that  such  complex  cases  are  rarely  met 
with  and  the  fact  that  they  may  appear  does  not  detract 
in  the  least  from  the  value  of  radiological  examination. 


CHAPTER  VIII 

AORTITIS 

IT  is  common  to  find  on  post-mortem  examination  many 
different  lesions  of  the  aorta  which  have  not  been 
recognized  during  life.  Sometimes  considerable  dilata- 
tions or  aneurisms  are  seen,  more  often  those  "middle 
states"  of  aortitis,  consisting  of  moderate  enlargement 
of  the  vessel  together  with  gelatiniform  or  atheromatous 
patches  on  the  walls.  These  types  of  aortitis  may  escape 
observation  completely  and  not  be  indicated  by  any  per- 
ceptible sign  on  percussion  or  auscultation.  The  number 
of  these  accidental  autopsy  findings  will  diminish  with 
the  progress  of  radiology  which  already  shows  the  most 
minute  alterations  in  the  shape  of  the  aorta  in  the  in- 
cipient stages. 

I.     THE  AORTA   IN  THE   NORMAL 

Radioscopic  examination  of  the  right  aorta  should  be 
made  in  two  positions:  (1)  frontal  position,  the  screen  in 
contact  with  the  sterno-costal  wall;  (2)  oblique  position, 
the  patient  standing,  in  profile,  three-quarters,  etc., 
behind  a  fixed  screen,  parallel  to  the  plane  in  which  the 
tube  moves. 

1.  Frontal  Position.  The  examination  may  be  made 
in  two  ways  and  the  patient  observed  in  the  vertical 
position  or  in  recumbency;  it  is  always  necessary  to 
specify  which  has  been  used,  as  the  contours  of  the  aorta 
present,  as  the  case  may  be,  slightly  different  images. 

In  general,  the  tracing  shows  on  the  right  above  D 
(Fig.  144)  a  sinuous  line  reentrant  as  far  as  Ca  and  ap- 
preciably rectilinear  from  Ca  to  A.    In  its  first  course, 


AORTITIS 


193 


this  line  marks  the  superior  vena  cava ;  in  its  second  sec- 
tion, it  marks  the  contour  of  the  ascending  aorta.  This 
contour  rarely  goes  beyond  the  sternal  shadow  in  young 
patients ;  but  in  adults  it  may  overlap  it  slightly  without 
a  pathological  condition  being  indicated. 


Fig.  144.  CONTOUR  OF  THE  AOETA  AND  THE  HEART  IN  FRONTAL 

POSITION 


The  examination  of  the  left  side  of  the  patient  (right 
side  of  Fig.  144)  shows  that  from  A'  to  A"  is  a  semi- 
circular contour  of  especial  interest  for  it  represents  the 
projection  of  the  upper  descending  portion  of  the  aortic 
arch.  In  this  curved  line  there  are  two  points  to  con- 
sider: first,  the  importance  of  its  development  which  is 
naturally  greater  according  to  the  space  occupied  by  the 
aortic  arch,  and  then,  the  distance  which  separates  its 
point  of  origin  from  the  sterno-clavicular  articulation 
(st). 

The  aortic  semicircle  is  very  clear  in  adults,  still  more 
marked  in  the  old ;  it  may  be  lacking  in  children  and  the 
young.  When  there  is  a  volumetric  alteration  in  the 
vessel,  it  presents  a  more  or  less  considerable  increase 
and  the  estimate  of  it  constitutes  one  of  the  essential 
elements  of  the  description  of  the  aorta.  This  will  be 
considered  presently. 


194 


THE  HEART  AND  THE  AORTA 


The  distance  which  separates  point  A',  origin  of  the 
aortic  semicircle,  from  the  sterno-clavicnlar  articulation 
(st),  varies  according  to  the  age  of  the  patient  and  the 
more  or  less  considerable  development  of  the  arch  of  the 
aorta.  In  normal  adults  the  line  which  marks  the  left 
outline  of  the  sternum  from  the  clavicle  to  point  A'  is  on 
the  average  2  to  3  centimeters.  Its  length  diminishes  in 
the  old,  and  point  A'  may  be  close  to  the  sterno-clavicular 
articulation,  especially  in  patients  with  a  short  thorax. 
The  upper  point  of  the  aortic  semicircle  never  does  over- 
lap the  line  which  marks  the  shadow  of  the  left  clavicle 
unless  aneurism  of  the  aortic  arch  is  present. 

The  preceding  figure  is  much  modified  according  to  the 
position  of  the  body  and  by  successive  respiratory  acts. 

In  the  vertical  position,  the  pericardial  sac  and  its  con- 
tents draw  the  vessels  at  the  base  to  the  medial  line  and 
cause  them  to  undergo  a  certain  elongation;  the  image 
of  the  aorta  is  then  attenuated  and  elongated.  In  dorsal 
recumbency,  on  the  contrary,  the  heart  is  pushed  up  and 
the  aortic  arch  is  broadened  (Fig.  145). 


Fig.  145 

Black   lines,    projection    in   recumbent    position;    dotted   lines,    standing 
position. 


AORTITIS 


195 


Respiration  causes  the  same  modifications.  The  arch 
is  lowered,  elongated  and  seems  to  contract  in  inspira- 
tion; in  expiration  it  rises,  broadens  out,  and  its  trans- 
verse diameter  is  increased.  These  modifications,  which 
are  as  a  rule  purely  physiological,  might,  if  they  were  not 
known,  lead  to  erroneous  interpretations.  It  is  impor- 
tant, therefore,  to  compare  with  each  other  tracings 
taken  only  in  identical  positions  and  in  shallow  respira- 
tion. 


Fig.  146.     EIGHT  ANTERIOR  OBLIQUE  POSITION  AT  45  DEGREES 


2.  Oblique  Position.  Examinations  in  the  oblique 
position  are  conveniently  made  in  the  vertical  position 
only,  which  allows  the  body  to  be  in  the  required  obliquity 
and  so  to  dissociate  the  vascular  shadows  from  the 
shadow  of  the  vertebral  column. 

The  right  anterior  oblique  position  is  the  most  favor- 
able for  the  examination  of  the  ascending  aorta.  It  is 
obtained  by  holding  the  patient's  right  shoulder  in  con- 
tact with  the  screen,  the  bi-scapular  axis  forming  with 
the  plane  of  the  screen  an  angle  of  varying  degree. 

Between  40  and  45  degrees  the  image  shown  in  Fig. 
146  is  obtained.  Above  the  shadow  of  the  heart  another 
shadow  will  be  noticed  stretching  to  the  right,  digitiform, 
with  parallel  contours,  which  rises  almost  vertically  to 


196 


THE  HEART  AND  THE  AORTA 


the  region  of  the  clavicle.  The  border  AD  is  sharply 
silhouetted  on  the  clear  field  of  the  left  lung  and  marks 
the  outside  of  the  ascending  portion  of  the  aortic  arch. 
The  inner  outline  joins  a  penumbra  A' A"  which  begins 
toward  the  superior  part  of  the  aortic  contour  and  grows 
larger  as  it  descends  toward  the  auricular  shadow.  This 
penumbra  is  due  to  the  projection  of  the  descending  por- 
tion of  the  arch  and  is  less  dense  than  the  first  because  the 
vessel  is  on  the  left  of  the  patient  and  consequently 
farther  from  the  screen.  Between  the  projection  of  the 
descending  aorta  and  that  of  the  vertebral  column  is  a 


Fig.  147 


Fig.  148 


Fig.   147.  EIGHT  ANTEEIOE  OBLIQUE   POSITION  AT  50  DEGEEES 
Fig.  148.    ANTEEIOE  OBLIQUE  POSITION  AT  60  DEGEEES 


clear  band  of  unequal  size  which  descends  to  the  level  of 
the  dome  of  the  diaphragm;  it  is  known  as  the  retro- 
cardiac  clear  space. 

A  greater  obliquity,  50  degrees,  for  example,  accen- 
tuates the  shadow  of  the  descending  aorta,  which  begins 
at  a  higher  point  (Fig.  147). 

The  image  obtained  with  an  obliquity  of  60  degrees  is 
one  of  the  most  instructive  (Fig.  148).  The  gray  shadow 
of  the  descending  aorta  occupies  a  still  more  important 


AORTITIS  197 

place  in  the  retro-cardiac  space.  Its  strongly  convex  out- 
line stands  out  clearly  from  the  shadow  of  the  ascending 
aorta,  with  its  rectilinear  outlines.  Here  the  top  of  the 
arch  presents  a  new  appearance ;  it  seems  to  enlarge  in 
the  form  of  a  beak  which  is  turned  toward  the  vertebral 
column  and  gives  a  dense  shadow;  this  is  the  fore- 
shortened projection  of  the  horizontal  portion  of  the  arch. 

The  aortic  shadow  in  oblique  position  is  one  of  the  most 
interesting  to  examine  closely ;  if  it  is  uniformly  enlarged 
in  the  form  of  a  club,  it  can  be  concluded  that  there  is  a 
fusiform  dilatation  of  the  vessel;  if  it  shows  in  pointed 
form  a  sac,  superadded  but  dependent  on  the  aorta,  it 
may  be  concluded  that  an  aneurismal  sac  exists ;  if  it  is 
only  more  sinuous,  with  contours  denser  than  usual, 
this  alteration  of  the  image  is  probably  due  only  to 
marked  modifications  in  the  disposition  and  the  anatomic 
structure  of  the  vessel. 

Examination  in  the  other  oblique  positions  does  not 
give  this  same  information.  However,  in  left  anterior 
oblique  position,  above  the  distention  of  the  pulmonary 
artery  a  portion  of  the  ascending  aorta  is  observed,  the 
shadow  of  which  is  not  covered  by  the  penumbra  of  the 
descending  aorta;  at  a  proper  angle,  the  contour  of  its 
outlines  is  clearly  seen;  it  is  also  easy  to  measure  the 
deviation  and  to  check  the  figure  of  the  diameter  obtained 
with  that  found  in  right  anterior  oblique  position. 

3.  Natuee  of  the  Information  Obtained.  Orthodia- 
graphic  examination  gives  a  projection  of  the  vessel 
which  is  not  deformed;  quantitative  or  rather  volumetric 
information  is  obtained  by  measuring  its  different  ele- 
ments. 

Fluoroscopic  examination  will  have  shown  the  more  or 
less  marked  flexuosity  of  the  vessel,  the  amplitude  of  its 
pulsations,  the  transparency  or  the  opacity  of  its  walls, 
all  indications  which  are,  so  to  speak,  qualitative. 

A.  Volumetric  analysis.  Three  dimensions  method. 
In  order  to  have  as  exact  an  idea  as  possible  of  the  dimen- 


198      THE  HEART  AND  THE  AORTA 

sions  of  the  thoracic  aorta,  it  is  necessary  to  make  on 
each  one  of  the  two  orthodiagrams,  one  in  the  frontal,  the 
other  in  the  right  anterior  oblique  position,  measurements 
in  the  regions  determined  on,  before  making  fixed  marks 
on  the  skin. 

The  right  anterior  oblique  tracing  (Fig.  147)  gives  the 
image  of  the  ascending  aorta  in  the  standing  position. 
A  horizontal  line  drawn  from  one  to  the  other  of  the 
parallels  which  delimit  the  artery  in  its  middle  portion, 
gives  the  measure  of  their  distance  apart  (line  d).  The 
caliber  of  the  vessel  in  its  ascending  course  will  thus  have 
been  established.     That  is  the  first  fixed  mark. 

On  the  tracing  in  the  frontal  position,  two  other  bear- 
ings are  taken:  the  first  corresponds  to  the  transverse 
diameter  of  the  arch,  the  second  to  the  chord  which  sub- 
tends the  left  aortic  semicircle. 

The  transverse  diameter  of  the  arch  is  represented  by 
the  maximal  distance  which  separates  the  contours  of  the 
aortic  shadow  on  the  right  and  left  of  the  sternum.  The 
two  most  salient  points,  not  being  at  the  same  height, 
cannot  be  joined  by  a  horizontal  line.  So  the  two  greatest 
semi-diameters  are  taken  terminating  in  the  medio- 
sternal  line  (lines  t  and  t'  of  Fig.  149),  and  together  they 
give  the  measure  of  the  transverse  diameter.  In  recum- 
bent position  this  diameter  exceeds  by  about  five  milli- 
meters that  in  the  vertical  position. 

The  measure  of  the  chord  which  subtends  the  left  aortic 
semicircle  gives  good  practical  indications  (line  A' A" 
Fig.  150).  This  chord  is  thus  defined:  above,  the  point 
where  the  convex  line  which  marks  the  arch  issues  'from 
the  mediastinal  shadow  and  begins  its  outline  on  the  left 
pulmonary  field;  below,  the  point  of  intersection  of  the 
semicircle  with  the  contour  of  the  pulmonary  artery 
(point  A"). 

Anatomically,  this  measurement  is  open  to  criticism, 
and,  moreover,  it  corresponds  to  only  a  part  of  the  de- 
scending aorta;  it  presents,  according  to  the  age  of  the 


AORTITIS  199 

patient,  a  remarkable  constancy.  But  in  order  that  it 
should  have  its  full  value  it  is  necessary  that  the  varia- 
tions should  not  be  assignable  to  any  extrinsic  cause,  for 
example  to  a  pushing  back  toward  the  left  of  the  medi- 
astinal organs,  caused  by  a  tumor,  an  effusion,  or  ad- 
hesions. 


Fig.  149  Fig.  150 

Fig.  149 

The  lines  t  and  t'  represent  the  two  transverse  semi-diameters. 

Fig.  150 
Line  A'A"  is  the  chord  which  subtends  the  left  aortic  semicircle. 


It  may  be  noted  that  the  chord  of  the  left  aortic  semi- 
circle varies  in  length  according  to  the  position  of  the 
patient.  In  a  general  way,  up  to  about  the  age  of  forty 
years,  it  is  3  to  5  millimeters  longer  in  the  standing  than 
in  the  recumbent  position. 

To  summarize,  therefore,  the  volumetric  analysis  of 
the  aorta  depends  on  the  evaluation  of  three  points  of 
measurement  which 'have  just  been  studied. 

From  a  large  number  of  healthy  patients,  the  figures 
corresponding  to  these  three  dimensions  have  been  taken 
and  are  presented  in  the  following  table: 


200      THE  HEART  AND  THE  AORTA 

TABLE  OF  THREE  DIMENSIONS 

Normal  Subjects.    Men.    Standing  Position 


Age 

Transverse 

diameter 

in  cm. 

Chord  of 

aortic  arch 

in  cm. 

Diameter  of 

ascending  aorta 

in  cm. 

16  to  20  years 
20  to  30  years 
30  to  40  years 
40  to  50  years 
50  to  60  years 
Over  60  years 

4  to  5 
5 

5  to  6 
5.5  to  7 

6  to  7 
6     to  8 

0     to  2.5 
2.5 

2.5  to  3.3 
2.8  to  3.5 
3     to  3.7 
3     to  4 

1.5  to  2 

2 

2     to  2.5 

2.5  to  2.8 

2.5  to  3 

3 

In  women  the  figures  are  generally  somewhat  lower. 

It  is  hardly  necessary  to  take  account  of  the  stature 
and  weight  of  the  patient,  which  give  only  slightly  appre- 
ciable differences;  however,  a  man  with  well-developed 
muscles  will  usually  show  the  extreme  dimensions  indi- 
cated in  the  table. 

With  these  reservations,  it  is  evident  that  the  age  of 
the  patient  is  the  most  important  factor  in  the  variations 
of  these  measurements;  that  is  the  conclusion  recently 
arrived  at  by  a  Japanese  writer,  Iwakichi  Kam.41  He 
has  examined  systematically  the  caliber  of  the  large  arter- 
ies of  the  body,  on  post-mortem,  and  has  shown  that  the 
circumference  of  the  aorta  increases  progessively  from 
birth  to  the  most  advanced  age,  its  caliber  being  greater 
at  the  same  age  in  man  than  in  woman. 

The  figures  which  have  just  been  given,  though  they 
are  only  relative,  nevertheless  constitute  a  practical  guide 
in  estimating  the  volume  of  the  aorta.  Though  their 
relations  cannot  be  expressed  by  mathematical  constants, 
yet  by  analyzing  them  carefully  important  deductions 
may  be  drawn  for  the  diagnosis  of  the  existence  and  the 
variations  of  aortic  dilatations,  however  slight  they 
may  be. 

4i  Iwakichi  Kam,  Virchow's  Archiv,  fiir  patliol.  Anat.,  Bd.  CCI,  1910. 


AORTITIS  201 

An  increase  in  the  three  diameters  indicates  that  the 
aorta  is  enlarged  equally  in  all  parts. 

A  predominant  increase  of  the  transverse  diameter, 
that  of  the  ascending  aorta  being  normal  and  the  chord 
slightly  developed,  ought  to  lead  to  the  conclusion  that 
the  aorta  broadens  under  the  costal  plastron,  the  arch 
describing  a  curve  of  large  radius. 

A  greater  increase  of  the  length  of  the  chord  than  of 
the  two  other  dimensions  without  elevation  of  the  top  of 
the  arch  means  only,  if  it  is  assumed  that  there  is  no 
aneurism,  an  enlargement  of  the  aorta,  very  low  and  due 
to  thoracic  aortitis. 

Finally,  a  marked  enlargement  of  the  chord  and  trans- 
verse diameter  with  elevation  of  the  top  of  the  arch,  the 
caliber  of  the  vessel  remaining  normal,  indicates  a  very 
sinuous  and  elongated  aorta. 

B.  Qualitative  analysis.  Radioscopy  furnishes  indi- 
cations concerning  the  state  of  the  arterial  walls,  based 
on  the  study  of  the  aortic  pulsations,  density  of  the 
shadow,  appearance  of  the  contour,  and  on  the  height  of 
the  arch. 

(a)  Aortic  pulsations.  In  general,  the  pulsations  of 
the  aorta  are  distinct  and  of  moderate  expansion.  Per- 
ceptible at  the  level  of  the  left  aortic  semicircle  and  along 
the  right  outline  of  the  ascending  aorta,  they  become 
feeble  pulsations  or  localized  undulations  at  the  level  of 
the  wall,  or,  again,  more  extended  oscillations,  displacing 
rhythmically  the  entire  arch  at  each  systole.  This  latter 
phenomenon  is  found  especially  in  patients  over  sixty 
years  old,  and  only  when  the  elasticity  of  the  arterial 
tunicce  is  diminished.  In  atheromatous  patients  or  in 
the  course  of  aortitis  with  thickening  of  the  walls,  the 
pulsations  become  barely  perceptible  or  disappear.  In 
other  cases,  on  the  contrary,  the  pulsations  are  greatly 
increased  in  amplitude,  and  especially  in  young  patients 
this  may  occur  without  any  organic  lesion. 

(b)  Density  of  the  aortic  shadow.    The  density  of  the 


202      THE  HEART  AND  THE  AORTA 

shadow  cast  by  the  aorta  should  be  observed  carefully 
in  the  course  of  radioscopic  examination;  it  may  vary 
more  or  less  according  to  the  condition  of  the  arterial 
walls. 

In  a  normal  subject  the  appearance  of  the  overlying 
portions  of  the  shadow  is  modified  according  to  the  age. 
In  the  adult  and  adolescent  this  shadow  is  plainly  gray, 
but  the  contour  is  very  visible  and  sharply  outlined 
against  the  transparency  of  the  lungs.  Its  opacity  is 
always  less  than  that  of  the  shadow  of  the  left  ventricle. 
In  the  aged  the  density  is  greater  and  approaches  that 
of  the  cardiac  shadow. 

In  the  pathological  state,  the  density  of  the  aorta  may 
be  as  great  as  that  of  the  heart,  sometimes  even  greater. 
Sometimes  the  opacity  of  the  vessel  affects  the  whole 
image  of  the  aorta;  sometimes  it  appears  as  spots  and 
patches,  irregularly  distributed  over  the  surface.  When 
these  spots  are  clearly  perceptible  in  the  intercostal 
>/  spaces  they  correspond  to  calcareous  plaques.  On  the 
other  hand,  in  certain  cases  usually  accompanied  with 
dilatation,  the  shadow  becomes  extremely  light,  as  com- 
pared with  the  cardiac  shadow. 

Finally,  it  may  happen  that  the  aortic  shadow  retains 
its  normal  density,  even  though  the  vessel  may  present 
evident  signs  of  enlargement. 

The  density  of  the  shadow,  then,  has  no  direct  relation 
to  the  volume  of  the  vessel,  nor,  consequently,  to  the 
amount  of  blood  in  it.  It  is  the  condition  of  the  walls, 
their  thickness,  and  especially  the  presence  of  calcareous 
plaques  which  greatly  accentuate  the  opacity  of  the 
shadow,  as  has  been  proven  by  examining  anatomical 
material. 

The  density  of  the  shadow  can  also  be  studied  in 
oblique  position. 

In  the  adult  the  shadow  of  the  ascending  aorta  and  the 
penumbra  of  the  descending  aorta  are  sometimes  difficult 
to  dissociate.    At  forty,  and  especially  over  sixty  years 


AORTITIS  203 

of  age,  the  ascending  portion  is  much  denser  and  cuts 
into  the  clearer  shadow  of  the  descending  portion.  This 
contrast  of  densities  is  even  more  marked  in  case  of  an 
atheromatous  artery. 

(c)  Contours.  The  shadows  of  the  aorta  are  interest- 
ing to  observe  in  the  frontal  and  oblique  positions.  The 
portions  which  overlap  the  median  shadow  have,  in  the 
frontal  position,  a  curvilinear  contour  with  no  irregu- 
larities ;  the  left  salient  is  bounded  by  a  circular  arc.  In 
the  pathological  state  these  contours,  independent  of  their 
enlargement,  show  in  certain  cases  abrupt  angles  or 
appreciable  sinuosities. 

In  the  right  anterior  oblique  position,  the  lines  of  the 
image  of  the  ascending  aorta  were  seen  to  be  parallel 
and  most  often  rectilinear.  In  the  pathological  state 
these  may  show  unequal  curves  which  describe  perfectly 
characteristic  sinuosities.  The  top  of  the  arch  sometimes 
shows  a  certain  degree  of  distention. 

Finally,  when  the  thoracic  aorta  is  dilated  or  simply 
sinuous,  the  descending  portion  is  outlined,  in  the  oblique 
position,  by  a  more  or  less  irregular  curve  somewhat  near 
the  vertebral  shadow. 

(d)  Height  of  the  arch.  It  has  been  indicated  above 
how  to  estimate  in  the  frontal  position  the  height  of  the 
arch  and  its  variations  in  the  normal.  This  height  in- 
creases in  certain  types  of  aortitis.  This  indication  will 
be  verified  by  examination  in  the  oblique  position,  by 
noting  the  position  of  the  transverse  aorta  in  relation  to 
the  clavicle,  the  patient  standing  with  arms  hanging 
down. 

It  may  be  said,  therefore,  that  the  general  condition  of 
the  aorta,  as  determined  by  radiological  examination,  is 
represented  by  two  series  of  parallel  analysis  : 

1.  Volumetric  analysis  depending  on  the  three  dimen- 
sions method : 

The  transverse  diameter  of  the  arch ; 

The  chord  of  the  left  aortic  semicircle ; 


204      THE  HEART  .AND  THE  AORTA 

The  diameter  of  the  ascending  aorta. 

This  analysis  gives  the  real  dimensions  of  the  aortic 
shadow. 

2.  Qualitative  analysis  which  furnishes  important  in- 
formation on  the  density  of  the  arterial  walls,  their  more 
or  less  great  elasticity,  the  elongation,  the  spreading  of 
the  arch,  the  rigidity  or  flexuosity  of  the  outlines. 

These  data  will  be  applied  to  the  study  of  the  pathologi- 
cal aorta. 

II.     THE  AORTA  IN  THE  PATHOLOGICAL  STATE 

Clinical  observation  gives  two  sets  of  facts  which  are 
very  unlike  but  in  each  of  which  the  aid  of  radioscopic 
and  orthodiagraph^  examination  is  indispensable. 

The  first  category  of  cases  concerns  patients  who, 
whether  or  not  complaining  of  subjective  disturbances 
which  may  be  properly  ascribed  to  a  lesion  of  the  aorta, 
nevertheless  have  such  a  lesion,  as  objective  examination 
proves. 

The  second  category  includes  patients  who  have  identi- 
cal disturbances  logically  ascribed  to  an  analogous  affec- 
tion which,  however,  cannot  be  confirmed  by  any  of  the 
methods  ordinarily  used. 

A.  Case  in  which  the  diagnosis  of  aortitis  is  evident 
after  objective  examination.  The  subjective  disturbances 
which  point  to  an  alteration  in  the  aorta  consist  ordi- 
narily of  dyspnoea  on  exertion,  of  permanent  or  parox- 
ysmal oppression,  in  the  form  of  asthma  or  pulmonary 
oedema  and  in  the  pains  which  frequently  accompany 
angina  pectoris. 

The  objective  signs  which  give  the  cause  of  these  dis- 
turbances are  furnished  by  percussion  and  auscultation. 

The  auscultatory  findings  are  often  doubtful;  some- 
times altogether  negative.  Sometimes  only  a  systolic  or 
diastolic  murmur  or  a  double  murmur  at  the  base  of  the 
heart  is  obtained ;  but  that  mean's  only  that  the  lesion  has 
extended  to  the  aortic  valves.    These  murmurs  may  be 


AORTITIS  205 

lacking  even  when  the  diagnosis  of  aortitis  is,  for  other 
reasons,  quite  evident;  they  may  exist  without  any  altera- 
tion in  the  vessel  beyond  the  valvular  area.  Often  the 
pathological  sounds  are  reduced  to  a  metallic  sound  or  to 
an  accentuation  of  the  second  aortic  sound. 

The  resources  of  palpation  and  percussion  are  more 
valuable ;  they  consist  in  the  determination  of  three  signs 
which  may  exist  together  or  singly:  a  superelevation  of 
the  right  subclavian  artery  above  the  clavicle,  a  salience 
of  the  aortic  dome  in  the  sternal  notch  and  an  overlapping 
of  the  dullness  of  the  aorta  on  the  right  side  of  the  ster- 
num at  the  level  of  the  first  intercostal  spaces.  The  figure 
resulting  from  this  latter  anomaly  represents  fairly  well 
the  crest  of  a  helmet,  whence  the  name  "matite  en 
casque"  (Potain). 

When  this  sign  is  present,  and  especially  when  it  is 
accompanied  by  the  two  other  anomalies  described  above, 
dilatation  of  the  arch  of  the  aorta  can  be  diagnosed.  But 
if  this  sign  is  lacking  the  conclusion  that  there  is  no  lesion 
of  the  vessel  is  not  justified,  because  it  may  be  altered  in 
some  other  part  causing  the  same  subjective  symptoms. 

In  cases  in  which  diagnosis  of  aortitis  with  dilatation 
of  the  arch  is  made  by  the  combination  of  subjective  dis- 
turbances and  of  signs  furnished  by  direct  examination, 
for  example  in  Hodgson's  disease,  it  might  seem  there- 
fore that  radioscopy  would  be  unnecessary.  It  is  not  so, 
because  radioscopy  enables  the  results  of  palpation  and 
percussion  to  be  checked  and  completed,  which  is  an  ap- 
preciable advantage,  and  the  evolution  of  the  lesion  to 
be  determined  by  examinations  made  at  different  stages. 

Orthodiagraphy  has  demonstrated  the  value  of  per- 
cussion :  this  assertion  is  true  for  percussion  of  the  heart, 
and  equally  so  for  percussion  of  the  aorta.  In  all  the 
cases  in  which  percussion  has  shown  that  a  dilatation  of 
the  vessel  at  its  point  of  origin  existed,  orthodiagraphy 
has  confirmed  it.    One  example  is  given  here : 

A  man  forty  years  of  age  complains  of  subjective  dis- 


206 


THE  HEART  AND  THE  AORTA 


turbances  which  make  possible  a  diagnosis  of  Hodgson's 
disease. 

Objective  examination  shows  an  elevation  of  the  aortic 
arch  above  the  sternal  notch  and  of  the  subclavian  above 
the  clavicle.  Percussion  of  the  aorta  shows  the  existence 
of  a  dull  area  in  the  form  of  a  helmet. 


Fig.  151 


Fig.  152 


Fig.  151.     AOETA  SLIGHTLY  ENLARGED,  AECH  ELEVATED 

Fig.  152.     SAME  CASE,  IN  RIGHT  ANTERIOR  OBLIQUE  POSITION 

AT  50  DEGREES 

Orthodiagraphic  examination  gives  the  images  shown 
in  Figs.  151  and  152  and  the  description  of  the  aorta  may 
be  expressed  in  the  following  manner : 

Volumetric  analysis:  three  dimensions  method: 

Transverse  diameter  =  8  centimeters. 

Chord  =  4  centimeters. 

Diameter  of  the  ascending  aorta  =  3  centimeters. 

Qualitative  analysis: 

(a)  Pulsations  very  weak. 
,,  (b)  Dense  shadow;  ascending  aorta  distinctly  visible, 
v  (c)   Contours  flexuous,  abrupt  angles  (in  frontal  posi- 
tion). 
''(d)  Top  of  the  arch  elevated. 

Conclusion:  Aorta  slightly  enlarged,  arch  raised,  ivalls 
thickened. 


AORTITIS  207 

As  will  be  seen,  the  radiological  indications  confirm  the 
percussion  findings.  The  distention  of  the  vessel  is 
affirmed  and  its  exact  position  determined,  at  the  same 
time  the  facts  which  might  escape  the  ordinary  methods 
of  investigation  are  accurately  given,  namely,  diminution 
of  the  elasticity  of  the  arterial  walls,  their  flexuosity  and 
thickening. 

If  it  is  sometimes  difficult,  clinically,  to  verify  the  ex- 
istence of  aortic  changes,  it  is  still  more  difficult  to  judge, 
some  months  later,  the  way  in  which  they  have  developed. 
The  interpretation  of  the  data  furnished  by  ordinary 
methods  of  investigation  leads  too  often  only  to  uncertain 
results.  The  interpretation  of  subjective  symptoms  is 
no  less  deceptive.  Prognosis  remains  often  most  obscure 
in  cases  of  aortitis. 

Under  such  circumstances  radiology  seems  most  val- 
uable by  giving  precise  information.  Two  convincing 
cases  are  reported  here.  In  the  first  case  orthodiagraphy 
confirmed  the  clinical  impressions  by  showing  a  clear  re- 
gression of  the  aortic  lesions  corroborated  by  a  corre- 
sponding amelioration  of  the  subjective  symptoms.  In 
the  second  case,  on  the  contrary,  it  revealed  a  progressive 
aggravation  of  the  lesions  of  the  aorta  and  thus  revised 
a  prognosis  which  according  to  the  ordinary  methods  of 
clinical  investigation  would  not  have  been  considered 
unfavorable. 

The  first  was  a  man  fifty-eight  years  of  age  examined 
March  6,  1910;  he  had  been  suffering  for  some  months 
from  dyspnoea  which  grew  worse  after  exertion.  Several 
times  during  exertion  he  had  attacks  of  frothy  and  bloody 
expectoration.  Marked  increase  of  arterial  pressure, 
marked  increase  of  the  aortic  dullness  "matite  en 
casque,"  with  an  overlapping  of  about  2  centimeters  on 
the  right  side  of  the  sternum.  The  right  subclavian  was 
perceptibly  above  the  clavicle.  The  heart  was  hyper- 
trophied ;  the  pulsation  of  the  apex  was  in  the  lower  part 
of  the  sixth  intercostal  space,  below  the  nipple. 


208 


THE  HEART  AND  THE  AORTA 


In  June,  1910,  the  patient  was  treated  at  Royat  by 
Heitz.  In  July  he  returned  much  improved.  The  sub- 
jective symptoms  had  moderated  and  percussion  indi- 
cated a  regression  of  the  signs  previously  found.  The 
apex  of  the  heart  had  lifted,  the  area  of  cardiac  dullness 
had  diminished  and  the  aorta  only  slightly  overlapped  the 
right  side  of  the  sternum.  The  resulting  favorable 
impression  was  confirmed  by  radioscopy  (Fig.  153). 


Fig.  153.     CASE  OF  IMPEOVEMENT 
Black  lines,  first  tracing ;  dotted  lines,  tracing  after  treatment. 

An  earlier  examination,  made  in  May,  1919,  furnished 
the  following  results : 

Aorta.    Volumetric  analysis: 

Transverse  diameter  =  9.5. 

Chord  =  5.6. 

Diameter  of  ascending  aorta  =  3.5. 

Qualitative  analysis: 

(a)  Pulsations  weak. 
,    (b)  Shadow  rather  dense. 

(c)  Contours  parallel. 

(d)  Top  of  the  arch  slightly  elevated,  about  1  centi- 
meter below  the  sterno-clavicular  articulation  in  frontal 
position. 


AORTITIS  209 

Conclusion:  Aorta  regularly  and  notably  enlarged  and 
slightly  thickened. 

Heart  much  enlarged. 

Longitudinal  diameter  =  20  centimeters. 

Horizontal  diameter  =  22.3  centimeters. 

Left  ventricular  outline  markedly  convex. 

Apex  much  rounded.  Right  ventricle  descends  4  centi- 
meters below  the  diaphragm. 

In  July,  1910,  after  treatment,  the  radioscopic  descrip- 
tion is  as  follows : 

Aoeta.    Volumetric  analysis: 

Transverse  diameter  =  7.6  centimeters. 

Chord  =  4.8  centimeters. 

Diameter  of  the  ascending  aorta  =  3  centimeters. 

Top  of  the  arch  not  so  high. 

Heart.    Longitudinal  diameter  =  19  centimeters. 

Horizontal  diameter  =  19.9  centimeters. 

The  right  ventricle  has  decreased  in  volume  and  de- 
scends only  2  centimeters  below  the  diaphragm. 

The  improvement  is  definite,  as  proved  by  the  clinical 
examination  and  radiological  findings  but  considering  the 
precision  of  the  radiological  findings,  it  cannot  be  re- 
garded as  superfluous. 

Here,  on  the  other  hand,  is  a  case  in  which  the  aggrava- 
tion of  the  phenomena  was  distinctly  brought  out  by 
radioscopy  when  other  methods  had  failed  to  establish  it. 

M.  de  B.,  fifty  years  of  age,  dyspnoea  on  exertion  for 
some  months,  nocturnal  oppression  and  palpitation. 
Objective  examination  shows  a  double  aortic  lesion  with 
dilatation  of  the  vessel  at  its  point  of  origin,  character- 
ized by  dullness  "matite  en  casque"  and  elevation  of  the 
right  subclavian.  The  patient  was  immediately  put  under 
treatment.  The  attacks  of  oppression  decreased  and  he 
was  able  to  resume  a  very  active  life.  A  year  later,  the 
grave  symptoms  no  longer  appeared ;  the  objective  signs 
continued  but  were  not  appreciably  increased.  On  ortho- 
diagraph^ examination,   a  most  manifest  and  serious 


210      THE  HEART  AND  THE  AORTA 

modification  in  the  condition  of  the  heart  and  aorta  was 
found. 


Fig.  154.     CASE  OF  AGGBAVATION 
Black  lines,  first  tracing;  dotted  lines,  second  tracing. 

The  tracings  (Fig.  154)  show  this.  The  dimensions  of 
the  heart  and  aorta  are  appreciably  increased.  The 
aortic  arch  shows  increased  transverse  diameter  and 
chord  and  a  decidedly  elevated  top.  The  longitudinal 
diameter  of  the  heart  has  increased  from  18.4  cm.  to  19.7 
cm.,  and  the  horizontal  diameter  from  17.5  cm.  to  19.5  cm. 

R-adiological  examination  was  found  to  be  correct  as 
against  clinical  examination,  the  prognosis  was  therefore 
much  more  alarming  than  had  been  supposed.  Some 
months  later  the  patient  was  seized  with  an  attack  of 
acute  aortitis  with  cardiac  and  aortic  distention  and 
succumbed  immediately  in  full  asystolism. 

B.  Cases  in  which  the  subjective  symptoms  of  aortitis 
are  not  accompanied  by  any  objective  sign.  It  occurs 
frequently  that  the  diagnosis  of  aortitis  ought  to  be  sus- 
pected, in  spite  of  the  absence  of  definite  objective  signs, 
and  because  of  the  existence  of  subjective  disturbances 
which  are  sufficiently  characteristic  to  warrant  it.  Cases 
of  this  kind  include  acute  and  chronic  progressive  aor- 
titis.   Examples  are  presented  here : 


AORTITIS 


211 


A  patient  forty-eight  years  of  age  returned  home  in 
the  morning  after  a  fatiguing  night.  At  the  moment  of 
retiring  he  was  suddenly  seized  with  severe  pain  in  the 
retro-sternal  region,  extending  toward  the  back  between 
the  shoulder  blades  with  irradiations  to  the  shoulders, 
especially  the  left  and  even  to  the  jaws.  The  face  was 
pale  and  drawn,  respiration  rapid  and  shallow.  The  pain 
lasted  several  hours,  accompanied  by  fine  rales  in  the 
chest,  then  it  diminished  progressively  to  reappear  for 
a  short  time  the  next  day,  leaving  behind  a  sensation  of 
extreme  prostration. 

From  the  combination  of  these  symptoms,  a  diagnosis 
of  acute  aortitis  with  angina  pectoris  was  made.  The 
objective  examination,  however,  gave  no  other  indication. 
The  arterial  tension  was  normal.  Percussion  and  auscul- 
tation were  negative. 

Some  days  later  radioscopic  examination  (Figs.  155 
and  156)  left  no  doubt  of  the  existence  of  lesions  which 
had  only  been  suspected. 


Fig.  155 


Fig.  156 


Fig.  155.     ACUTE  AORTITIS 

Fig.  156.     SAME  CASE,  IN  RIGHT  ANTERIOR  OBLIQUE  POSITION 
AT  50  DEGREES 


212      THE  HEART  AND  THE  AORTA 

The  detailed  description  of  the  aorta  is  as  follows : 

Aoeta.    Volumetric  analysis:    • 

Transverse  diameter  =  9.8  centimeters. 

Chord  =  5  centimeters. 

Ascending  aorta  =  4  centimeters. 

Qualitative  analysis: 

(a)  Pulsations  imperceptible. 

(b)  Shadow  rather  dense  in  oblique  position. 

(c)  Contours  parallel. 

(d)  Top  of  the  arch  slightly  elevated. 
Conclusions:    Aorta    uniformly    enlarged    in    rather 

marked  proportions ;  the  top  of  the  arch  is  not  elevated, 
but  the  vessel  appears  rather  dilated  below;  the  walls  are 
thickened. 

Cases  of  acute  aortitis  of  this  kind  are  far  from  excep- 
tional ;  we  have  met  several  similar  cases  in  which  radio- 
scopic  examination  showed  alterations  which  had  not  been 
found  by  the  ordinary  methods  of  investigation.  The 
same  thing  may  occur  in  chronic  aortitis.  The  following 
case  bears  this  out. 

M.  X.,  fifty-eight  years  of  age,  for  six  months  previous 
had  had  typical  attacks  of  angina  pectoris.  These  oc- 
curred especially  after  eating  and  during  rapid  walking. 
They  began  in  the  epigastrium,  then  moved  upward 
behind  the  sternum  and  finally  localized  over  the  chest 
causing  the  usual  shooting  pains.  For  some  months  the 
attacks  had  become  especially  painful. 

The  obvious  clinical  diagnosis  was  angina  pectoris  due 
to  aortitis  or  rather  angina  in  its  gastralgic  form  (angina 
abdominis) ;  this  diagnosis,  however,  depended  exclu- 
sively on  subjective  symptoms,  for  objective  examination, 
by  percussion  and  auscultation,  did  not  reveal  any  appre- 
ciable modification  of  the  aorta. 

The  result  of  radiological  examination  was  quite  dif- 
ferent (Figs.  157  and  158).  It  showed  that  a  very  marked 
alteration  of  the  vessel  existed  since  the  transverse  diam- 
eter measured  9.9  cm.,  the  chord,  5  cm. ;  the  diameter  of 


AORTITIS  213 

the  ascending1  aorta  was  almost  double  the  normal.  The 
shadow  of  the  vessel  was  very  light.  The  top  of  the  aortic 
arch  was  not  much  elevated,  which  explained  the  negative 
results  of  percussion  and  palpation.  On  the  contrary  the 
dilatation  of  the  vessel  was  very  slight,  as  was  proved  by 
elongation  of  the  chord,  and  by  the  results  of  oblique 
examination  of  the  aorta.  In  gastralgic  or  abdominal 
angina,  this  has  been  previously  observed. 


Fig.  357 


Fig.  15S 


Fig.  157.     CHEONIC  AORTITIS 

Fig.  158.     SAME  CASE,  IN  RIGHT  ANTERIOR  OBLIQUE  POSITION 
AT  50  DEGREES 


Such  conflicting  results  from  the  different  methods  of 
examination  are  easily  explained.  Percussion  and  pal- 
pation can  determine  only  the  existence  of  a  dilatation 
of  the  aortic  arch,  for  that  is  all  that  gives  perceptible 
signs ;  namely,  the  overlapping  of  the  vessel  on  the  right 
of  the  sternum  as  a  result  of  the  exaggeration  of  the  curve 
of  the  arch,  the  elevation  of  the  top  of  the  aorta  in  the 
sternal  notch,  and  the  elevation  of  the  subclavian  above 
the  right  clavicle.  These  modifications  are  peculiar  to 
Hodgson's  disease  and  that  is  why  this  disease  rarely 
escapes  detection.  The  other  types  of  dilatation  are  nat- 
urally not  apparent  by  percussion  and  palpation.  It  is 
not  the  same  with  radiological  examination  which  can,  as 
the  preceding  case  shows,  give  valuable  evidence,  even  in 


214      THE  HEART  AND  THE  AORTA 

cases  in  which  the  dilatation  is  located  in  another  part 
of  the  vessel. 

There  are,  however,  types  of  aortitis  which  are  not 
accompanied  by  any  modification  of  the  quantitative  or 
volumetric  aortic  signs;  for  this  reason  such  types  of 
aortitis  do  not  cause  deformations  perceptible  by  fluoros- 
copy. Nevertheless,  in  an  indirect  manner,  these  types 
of  aortitis  can  be  determined  by  changes  in  the  qualitative 
characteristics  in  the  shadow  of  the  vessel. 

Ordinarily  these  cases  are  shown  on  the  tracings  in  the 
direct  position.  The  transverse  diameter  is  slightly  in- 
creased, the  salience  of  the  left  semicircle  projects  rather 
high  under  the  left  clavicle,  as  a  result  of  the  elongation 
and  the  tortuosity  of  the  vessel.  But  in  the  oblique 
position  its  caliber  maintains  its  normal  dimensions.  The 
conclusion  can  then  be  drawn,  that  there  is  no  notable 
alteration.  In  spite  of  this,  the  diagnosis  of  aortitis 
should  nevertheless  be  made  when  there  is  opacity  of  the 
vascular  shadow  coincident,  fairly  often,  with  spots  and 
dense  patches  due  to  areas  of  calcareous  infiltration,  and 
the  more  or  less  complete  absence  of  vascular  pulsations, 
indicating  thickening  and  rigidity  of  the  walls  of  the 
artery.    We  have  seen  several  cases  of  this  kind. 

The  essential  subjective  phenomenon  which  character- 
izes them  consists  in  more  or  less  violent  pain,  in  the  form 
of  angina  attacks,  intense,  repeated  and  lasting.  This 
type  of  aortitis  usually  seems  to  imply  a  serious  prog- 
nosis. It  resists  treatment,  and  it  is  not  uncommon  to 
note  in  the  course  of  radiological  examinations  made  at 
intervals  of  several  months  the  progressive  invasion  of 
the  aorta  by  sclerosis,  the  appearance  of  new  opaque 
spots  and  the  gradual  increase  in  the  diameters  of  the 
vessel. 

These  types  of  aortitis,  as  a  rule,  cannot  retrogress 
except  when  they  are  due  to  syphilis.  But  in  that  case 
treatment  gives  beneficial  results.  It  diminishes  the  at- 
tacks of  pain  and  acts  on  the  lesion  itself,  for  radiological 


AORTITIS  215 

examination  reveals  a  diminution  in  the  opacity  of  the 
arterial  walls  with  progressive  reappearance  of  the  pul- 
sations, indicating  that  the  walls  of  the  vessel  are  resum- 
ing their  normal  elasticity. 

The  preceding  considerations  have  a  considerable  im- 
portance. 

If  lesions  of  the  aorta  have  too  often  remained,  up  to 
the  present  time,  resistant  to  therapeutic  measures,  it  is 
because  their  usual  cause  is  ordinarily  misunderstood  and 
the  methods  of  treatment  used  not  very  efficacious; 
finally,  intervention  was  too  late,  introduced  when  the 
alterations  were  already  irremediable. 

The  situation  is  different  now.  We  know  that  syphilis 
plays  an  especially  important  part  in  the  development  of 
aortic  lesions;  we  have  in  the  Wassermann  reaction  a 
valuable  method  of  verifying  it.  On  the  other  hand,  the 
therapeutic  resources  at  our  disposal  have  an  efficacy 
which  is  no  longer  open  to  doubt.  The  part  of  the  clini- 
cian here,  as  everywhere,  is  to  recognize  the  lesion  as 
soon  as  possible  after  its  first  appearance,  for  thera- 
peutic success  depends  on  early  diagnosis.  Radiology 
will  therefore  enable  the  alterations  of  the  aorta  to  be 
demonstrated  at  a  stage  in  which  they  were  hitherto  not 
recognized.  Radiology  gives  the  exact  description  of  the 
diseased  aorta,  allows  the  early  recognition  of  the  lesion, 
and  permits  us  to  follow  its  development ;  it  is  the  indis- 
pensable complement  of  every  clinical  investigation  and 
the  most  reliable  means  of  checking  whatever  therapeu- 
tic measures  may  be  used. 


CHAPTER  IX 

ANEURISMS  OF  THE  THORACIC  AORTA 

IN  the  preceding  chapter,  the  study  was  limited  to  the 
more  or  less  extended  lesions  of  the  aorta  leaving 
aside  aneurismal  dilatations  which  are  met  with  in  cases 
of  generalized  aortitis  but  which  also  develop  very  often 
as  isolated  tumors  affecting  only  a  small  portion  of  the 
vessel.  Although  it  may  be  somewhat  artificial  to  sepa- 
rate and  consider  aortitis  on  the  one  hand  and  aneurism 
on  the  other,  for  these  changes  are  frequently  due  to  the 
same  cause,  namely,  syphilis,  nevertheless  the  particular 
development  of  aneurisms  justifies  a  special  study  of 
them. 

Radiological  diagnosis  of  aneurism  of  the  thoracic 
aorta  is  sometimes  extremely  simple,  when  the  tumor  is 
large  and  easily  detected  by  fluoroscopy.  When  the 
aneurism  is  but  slightly  developed  and  concealed  by  medi- 
astinal shadows  the  significance  of  which  must  be  deter- 
mined, the  diagnosis  is  more  difficult.  The  following 
technic  seems  necessary  for  a  thorough  examination. 

First,  a  complete  radioscopic  inspection  of  the  thorax, 
which  according  to  Holzknecht  should  be  made  in  all  the 
positions :  direct  anterior,  direct  posterior  oblique  and 
above  all  in  right  anterior  oblique,  noting  the  successive 
modifications  of  the  shadows  in  changing  from  one  to  the 
other  of  these  positions. 

The  combination  of  these  movements  aims  to  make 
visible  the  different  appearances  of  the  aorta,  to  deter- 
mine whether  its  contours  are  regular  or  not  and  to 
estimate  the  degree  of  density.  In  order  to  carry  out 
these  procedures  and  to  have  an  exact  record  of  the  out- 


ANEURISMS  OF  THE  THORACIC  AORTA      217 

lines  of  the  vessel,  it  is  necessary  to  vary  the  angle  of 
the  rays  and  to  bring  the  normal  ray  tangent  to  the  entire 
extent  of  the  artery  outlines. 

After  the  examination  on  the  screen,  an  orthodia- 
graphic  tracing  in  the  selective  positions  is  taken  as  indi- 
cated by  the  preliminary  radioscopic  steps. 


Fig.  159 


Fig.  160 


Fig.  159.     ANEURISM  OF  THE  AOETA.     HOUEGLASS  FOEM 
Fig.  160.     SAME  CASE,  IN  EIGHT  ANTEEIOE  OBLIQUE  POSITION 


I.     GENERAL  ASPECT  OF  ANEURISMAL  SHADOWS 

A  description  of  the  different  images  of  large  aneu- 
risms will  be  given,  those  easily  demonstrated  by  x-rays, 
in  order  to  deduce  the  symptomatic  characteristics  which 
enable  the  more  difficult  diagnosis  of  smaller  and  dissimu- 
lated tumors  to  be  made. 

The  first  case  for  illustration  shows  an  aneurism  visible 
in  all  positions  like  that  shown  in  Figs.  159  and  160.  In 
the  frontal  position  the  mediastinal  shadow  is  deformed 
by  an  abnormal  dense  salience  overlapping  the  sternum 
on  the  right  in  the  first  intercostal  spaces,  on  the  left  at 


218 


THE  HEART  AND  THE  AORTA 


the  level  of  the  superior  arch,  and  broadening  out  into 
both  pulmonary  fields.  The  mediastinal  shadow  appears 
as  though  formed  of  two  superimposed  globular  shadows, 
in  the  form  of  an  hourglass,  the  upper  being  formed  by 
an  aneurismal  sac  larger  than  the  lower,  which  represents 
the  heart. 


Fig.  161 


Fig.  162 


Fig.  161.     ANEUEISM  OF  THE  ASCENDING  POETION  OF  THE 

AOETA 

Fig.  162.     SAME  CASE,  IN  EIGHT  ANTEEIOE  OBLIQUE  POSITION 


In  oblique  position  (Fig.  160),  the  aortic  shadow  be- 
comes completely  atypical;  the  parallelism  of  the  vascu- 
lar contours  disappears,  the  image  takes  the  form  of  an 
irregular  sac  with  both  anterior  and  posterior  enlarge- 
ment. The  extreme  contours  invade  almost  all  the 
anterior  clear  space;  the  posterior  clear  space  is  filled 
by  the  shadow  of  the  sac  which  at  an  angle  of  50  degrees 
merges  with  the  image  of  the  vertebral  column.  This 
case  is  a  question  of  a  large  aneurismal  dilatation  of  the 
ascending  and  the  descending  aorta. 

This  general  disposition  of  the  radioscopic  shadows  is 
found  in  all  aneurisms  that  are  easily  seen ;  but  they  are 
naturally  modified  in  relation  to  the  topographical  dis- 


ANEURISMS  OF  THE  THORACIC  AORTA      219 

position  of  the  sac.  The  objective  aspect  varies  accord- 
ing as  the  sac  is  on  the  ascending  portion,  on  the  top  of 
the  arch,  or  on  the  descending  portion  of  the  vessel.  The 
images  obtained  under  these  circumstances  are  presented 
here. 

Fig.  161  is  a  woman  forty-seven  years  of  age  with  a 
large  aneurism  of  the  ascending  portion  of  the  aorta, 
especially  at  its  origin.  The  aortic  shadow  in  the  right 
pulmonary  field  forms  a  very  sharp  angular  salience. 
The  contour  is  clear  and  without  indentations,  and  there 
is  no  pulsation.  In  spite  of  the  absence  of  this  latter  sign, 
the  diagnosis  is  none  the  less  positive.  The  development 
of  the  shadow  gives  evidence  of  a  sac,  for  the  transverse 
diameter  of  the  arch  is  12.7  cm. ;  moreover,  this  shadow  is 
dense  and  homogeneous.  In  the  left  pulmonary  field,  the 
aortic  arc  is  greater  in  height  than  in  depth;  the  chord 
of  the  arc  measures  5.6  cm.  The  contours  of  the  left 
semicircle  are  irregular  but  sharp  and  they  pulsate 
synchronously  with  the  pulse. 

If  the  patient  is  placed  in  the  right  anterior  oblique 
position  at  about  45  degrees,  the  resulting  image  is  that 
shown  in  Fig.  162.  The  top  of  the  aorta,  somewhat 
dilated,  extends  beyond  the  clavicle;  lower,  its  shadow 
extends  far  to  the  right  of  the  patient  and  obscuring  the 
retro-cardiac  clear  space  it  merges  with  the  shadow  of  the 
vertebral  column.  This  abnormal  salience  is  due  to  the 
angle  made  by  the  aneurism  in  the  frontal  position. 
"When  the  patient  is  placed  in  the  right  anterior  oblique 
position,  the  mediastinal  shadow  is  thrown  entirely  to  the 
left,  except  the  much  distended  sac  to  the  right  and 
toward  the  back  which  still  remains  partly  in  the  right 
plane  of  the  projection. 

This  combination  of  data  gives  a  diagnosis  of  an  aneu- 
rism of  the  aorta,  the  greatest  dimensions  of  which  corre- 
spond to  the  ascending  part  of  the  vessel.  Here  the  sac 
is  developed  not  only  outward  but  also  toward  the  depth 
of  the  thorax. 


220      THE  HEART  AND  THE  AORTA 

Figs.  163  and  164  are  of  a  woman  forty-six  years  of  age 
with  two  dilatations,  one  at  the  top  of  the  arch  and  the 
other  of  the  descending  aorta.  It  will  be  noted  that  this 
latter  does  not  appear  in  the  oblique  position,  which  leads 
to  the  conclusion  that  it  is  not  large ;  on  the  contrary,  the 
sac  at  the  top  is  shown  completely. 


Fig.  163  Fig.  164 


Fig.  163.     ANEURISM  OF  THE  TOP  OF  THE  ARCH  AND  OF  THE 
DESCENDING  AORTA 

Fig.  164.     SAME  CASE,  IN  RIGHT  ANTERIOR  OBLIQUE  POSITION 

An  example  of  the  image  formed  by  an  aneurism  of 
the  descending  portion  of  the  aorta  is  shown  in  Figs.  165 
and  166. 

In  the  anterior  direct  position  (Fig.  165),  it  is  the  left 
aortic  semicircle,  otherwise  called  the  superior  arc, 
which  is  abnormally  enlarged;  the  chord  which  subtends 
it  measures  8.4  cm.,  and  the  transverse  aortic  diameter 
has  the  same  length. 

In  the  right  anterior  oblique  position  (Fig.  166),  the 
exterior  contour  of  the  ascending  aorta  which  is  com- 
pressed toward  the  outline  of  the  thorax  is  traced  first 
to  the  right,  then  the  line  curves  in  at  the  top  of  the  arch 
and  begins  to  descend.  But  presently  it  rises,  goes 
toward  the  vertebral  column  and  circumscribes  in  the 


ANEURISMS  OF  THE  THORACIC  AORTA      221 

retro-carcliac  clear  space  an  irregular  shadow  which  indi- 
cates an  aneurism.  This  shadow  is  not  very  dense  and 
its  contours  are  rather  light  owing  to  the  fact  that  the 
descending  aorta  is  naturally  distant  from  the  plane  of 
the  screen. 

Only  typical  images  have  been  presented  here  in  which 
radiological  examination  has  simply  confirmed  the  clini- 
cal diagnosis,  at  the  same  time  that  the  details  of  the 
lesion  were  more  clearly  noted.  There  are  other  cases, 
however,  which  are  especially  interesting,  in  which  less 
developed  aneurisms  might  escape  clinical  and  even  radio- 
logical examination  if  it  were  not  made  with  an  exact  and 
appropriate  method.  This  method  depends  on  the  analy- 
sis of  special  details  which  should  be  understood  thor- 
oughly and  which  consist  above  all  in  the  abnormal 
topographical  disposition  of  the  observed  shadow,  the 
atypical  character  of  the  aortic  contours,  their  clearness 
in  examination  on  the  screen  and  their  pulsations.  It  is 
the  combination  of  these  details  which  has  enabled  us,  in 
the  cases  which  are  to  be  recorded,  to  arrive  at  a  final 
diagnosis  later  confirmed  by  post-mortem. 


Fig.  165  Fig.  166 


Fig.    165.     ANEUBISM   OF   THE   DESCENDING   POETION   OF   THE 
AKCH  OF  THE  AOETA 

Fig.  166.     SAME  CASE,  IN  EIGHT  ANTEEIOB  OBLIQUE  POSITION 


222 


THE  HEART  AND  THE  AORTA 


Fig.  167  is  not  at  all  comparable  to  those  that  have  just 
been  described.  The  marked  characteristic  malforma- 
tions are  not  found  in  this  case.  In  the  frontal  position, 
the  aortic  shadow  overlaps  only  slightly,  on  both  sides, 
the  mediastinal  shadow  in  the  subclavian  region.  On  the 
left  it  projects  normally  in  the  first  intercostal  space, 
forming  an  arc  slightly  exaggerated  but  not  excessive. 


Fig.  167 


Fig.  168 


Fig.    167.     ANEURISM   OF   THE    TRANSVERSE   PORTION   OF   THE 

ARCH 

Fig.  168.     SAME  CASE,  IN  RIGHT  ANTERIOR  OBLIQUE  POSITION 


Also  on  the  right,  the  protrusion  is  not  considerable,  but 
its  position  is  quite  abnormal;  it  is  situated  very  high 
under  the  right  clavicle ;  this  can  be  due  only  to  the  pres- 
ence of  a  sac.  If  it  were  a  question  of  aortitis,  that  is  to 
say,  a  cylindrical  dilatation  of  the  vessel,  the  salience  of 
the  arterial  shadow  would  show  itself,  in  the  right  field, 
much  nearer  the  cardio-vascular  angle  than  the  sterno- 
clavicular articulation.  Here  it  is  quite  the  contrary. 
Besides,  if  there  were  any  doubt  about  it,  that  would  be 
removed  by  the  fact  shown  in  Fig.  167,  that  the  top  of  the 
arch  is  elevated  as  far  as  the  sternal  notch  and  that  not- 
withstanding  the    superposition   of   the   vertebral    and 


ANEURISMS  OF  THE  THORACIC  AORTA      223 


sternal  shadows,  it  is  sufficiently  clear  to  be  indicated  by 
a  black  line.  Finally,  at  this  point  exaggerated  pulsa- 
tions of  the  sac  are  seen  on  the  screen. 

In  the  oblique  position,  the  diagnosis  is  still  more  clear ; 
Fig.  168  shows  that  the  aorta  is  deformed  in  the  shape  of 
a  club.  The  conclusion  to  be  drawn  from  these  indica- 
tions is  that  there  is  an  aneurism  of  the  transverse  por- 


Fig.  169  Fig.  170 

Fig.  169.    ANEURISM  OF  THE  EIGHT  CURVE  OF  THE  ARCH 
Fig.  170.     SAME  CASE,  IN  RIGHT  ANTERIOR  OBLIQUE  POSITION 

tion  of  the  arch.  The  radiological  characteristics  which 
justify  this  conclusion  are,  principally,  as  has  been  indi- 
cated above,  the  anomalous  position  of  the  shadow,  the 
atypical  aortic  contours,  their  clearness  on  the  screen  and 
their  pulsations. 

Figs.  169  and  170  show  a  case  of  aneurism  of  the  aorta 
in  which  the  clinical  and  the  radiological  diagnosis  were 
still  more  difficult,  based  only  on  a  slight  development  of 
the  sac  and  its  unusual  position.  Clinically  there  was 
found  in  the  first  right  intercostal  space  a  very  slight  up- 
ward curvature  with  pulsations  giving  a  thrill  on  palpa- 
tion. On  the  screen  the  atypical  character  of  the  tracing 
by  its  clearness  was  enough  to  establish  a  diagnosis.    In 


224      THE  HEART  AND  THE  AORTA 

Fig.  169  this  atypical  condition  of  the  outlines  showed 
itself  by  a  bulging  of  the  right  aortic  contour  situated 
very  high  near  the  right  clavicle. 

In  the  right  anterior  oblique  position,  the  caliber  of  the 
aorta  was  enlarged,  and  moreover,  there  was  a  more 
marked  dilatation  above  and  at  the  right,  giving  to  the  top 
of  the  aorta  a  clublike  form,  the  maximum  salience  of 
which  corresponded  to  the  external  thoracic  contour. 
The  conclusion  then  was  that  there  was  a  uniform  dilata- 
tion of  the  aorta  and,  moreover,  an  aneurism  at  the  point 
of  the  right  curve.  This  diagnosis  was  definitely  con- 
firmed by  autopsy. 

Sometimes  the  interpretation  of  radiological  images  is 
still  more  difficult  because  the  factors  of  diagnosis  appear 
only  in  one  of  the  positions,  the  other  furnishing  no  indi- 
cation which  can  be  depended  on.  It  is  then  necessary  to 
remember  the  rule,  which  has  been  insisted  on,  not  to 
affirm  the  complete  integrity  of  the  vessel  under  observa- 
tion until  after  methodical  radiological  examination  in 
all  positions  which  it  is  possible  to  have  the  patient  take 
in  front  of  the  screen.  Here,  also,  the  importance  is 
apparent  of  adding  to  radiographic  images  orthodia- 
graphic  tracings  and  at  the  same  time  the  data  resulting 
from  fluoroscopic  examination,  for  any  one  of  these  meth- 
ods used  alone  can  lead  only  to  uncertain  conclusions. 

An  example  is  given  in  Figs.  171  and  172.  The  case  is 
of  a  woman  fifty  years  of  age  with  an  enormous  prester- 
nal  pulsating  tumor.  Now,  by  examining  Fig.  171  there 
is  seen  in  the  frontal  position  the  shadow  of  the  arch  over- 
lapping the  sternum  on  both  sides  in  exaggerated  propor- 
tions but  not  very  considerable.  A  study  of  this  image 
would  leave  no  doubt  of  the  importance  of  the  aortic 
lesion;  but  in  right  lateral  position  (Fig.  172),  the  general 
appearance  completely  changes.  An  enormous  sac  is  seen 
which  projects  across  the  sternum  and  exceeds  it  by  7  cm. 
If  the  lack  of  information  on  examination  in  the  frontal 
position  in  contradiction  to  the  importance  of  the  findings 


ANEURISMS  OF  THE  THORACIC  AORTA      225 

in  the  oblique  position  has  only  mediocre  significance, 
assuming  the  certainty  of  the  diagnosis,  it  is  understand- 
able that  it  is  not  the  same  if  the  tumor  is  hidden  in  the 
mediastinum  or  if  it  escapes  other  methods  of  examina- 
tion. 


Fig.  171  Fig.  172 


Fig.  171.     LAEGE  SAC  IN  THE  POSTEBIOE-ANTEEIOE  DIEECTION 
OF  THE  ASCENDING  POETION 
Few  signs  in  the  frontal  position. 

Fig.  172.     SAME  CASE,  IN  EIGHT  ANTEEIOE  OBLIQUE  POSITION 

This  is  seen  as  well  in  aneurisms  of  the  descending 
aorta,  which  often  appear  only  on  oblique  examination,  as 
in  the  case  of  the  aneurisms  of  the  antero-superior 
portion  of  the  arch. 

Barjon42  has  described  a  typical  example.  Speaking  of 
this  type  of  aneurism  he  says : 

"This  aneurism  is  situated  on  the  median  line,  behind 
the  sternum,  below  the  sterno-clavicular  articulation,  at  a 
point  where  the  median  shadow  is  broad  and  where  the 
normal  aorta  regularly  overlaps  it  on  the  left  side.  Noth- 
ing then  is  visible  in  frontal  examination.     If  we  are 

42  Barjon,  Anevrisms  de  I'aorte  et  tumeurs  du  mediastinum,  Paris  Medi- 
cal, 6  Janvier,  1912. 


226      THE  HEART  AND  THE  AORTA 

looking,  with  our  minds  made  up,  for  an  aneurism,  we 
shall  easily  find  it  in  the  oblique  position.  That  happened 
to  me  in  the  case  of  a  patient  with  paralysis  of  the  left 
vocal  cord  which  led  me  to  suspect  aneurism.  There  was 
a-  regular  rounded  salience  which,  overlying  the  left  edge 
of  the  aorta,  filled  the  median  clear  space  and  touched  the 
vertebral  shadow"  (Fig.  173). 


Fig.  173.  ANETJEISM  OF  THE  ANTEEO-SUPEEIOE  PORTION  VISI- 
BLE ONLY  IN  EIGHT  ANTEEIOE  OBLIQUE  POSITION 
(BAEJON) 

II.     ANALYSIS  OF  SOME  RADIOLOGICAL  SIGNS 

The  study  of  the  particular  cases  which  have  been  taken 
as  examples,  in  which  there  were  aneurisms  more  or  less 
easy  to  diagnose,  has  resulted  in  the  recording  of  a  cer- 
tain number  of  radiological  characteristics  which  have 
only  been  mentioned.  A  detailed  study  will  be  taken  up 
of  each  of  these  signaletic  characteristics. 

(a)  Lack  of  parallelism  of  the  contours.  The  irregu- 
larity of  the  arterial  contours  is  one  of  the  most  impor- 
J  tant  signs  on  which  to  rely  in  diagnosing  aneurism  of  the 
aorta.  It  is  in  the  oblique  position,  where  the  whole 
length  of  the  aorta  is  seen  and  where  both  outlines  of  the 
ascending  portion  are  clearly  distinguishable,  that  we  can 
best  observe  a  modification  in  the  parallelism  of  the  con- 


ANEURISMS  OF  THE  THORACIC  AORTA      227 

tours.  If  an  aneurismal  sac  exists,  the  walls  of  the  vessel 
diverge  in  all  directions,  their  projection  on  a  plane  being 
represented  by  lines  irregularly  distant  from  each  other, 
recurved  and  then  decurved  to  make  the  ampullary  form 
of  aneurism.  The  resulting  images  appear  immediately 
quite  different  from  those  in  other  pathological  condi- 
tions; aortitis,  even  generalized,  increases  the  caliber  of 
the  vessel,  but  it  always  keeps  its  cylindrical  aspect; 
aortic  insufficiency  accompanied  by  an  arterial  lesion  like- 
wise deforms  the  vessel,  but  the  deformation  is  always 
situated  at  its  point  of  origin  and  presents  a  regular  conic 
form.  On  the  contrary,  the  irregularity  of  the  contours 
observed  in  a  case  of  aneurism  gives  at  once  the  impres- 
sion of  vascular  hernia  or,  in  a  word,  of  a  sac. 

In  the  direct  position,  the  lack  of  parallelism  of  the  con- 
tours is  represented  by  large  curves  and  is  distinct  from 
the  usual  outlines  of  glands  and  tumors,  which  are  gen- 
erally polycyclic  and  give  the  shadow  an  embossed 
appearance. 

(b)  Precision  of  contours.  The  contours  of  an  aneu-  * 
rism  are  usually  clear  and  linear.  There  is  a  striking  con- 
trast between  their  shadow  and  the  clear  pulmonary 
fields.  This  demarcation  is  especially  evident  on  radio- 
scopic  examination.  It  is  not  always  the  same  on  radio- 
graphic plates,  for,  as  Belot43  has  remarked,  a  pulsating 
tumor  cannot  on  account  of  its  pulsations  give  more  than 
a  hazy  image  on  a  plate,  even  if  it  is  taken  in  a  few 
seconds. 

Finally,  in  the  case  of  aneurism,  the  curves  are  rounded 
and  there  are  no  sharp  angles,  no  finger-like  prolonga-  t/ 
tions  such  as  are  seen  in  cancerous  tumors,  no  polycyclic 
contours  such  as  are  made  by  glands.  However,  these 
characteristics  are  not  pathognomonic.  It  may  happen 
that  the  mediastinal  tumors  are  marked  by  outlines  of 
perfect  clearness  simulating  arterial  walls.  On  the  con- 
trary, there  are  cases  in  which  the  vascular  contour  is  very 

43  Belot,  Societe  de  Kadiologie,  Seance  du  12  avril,  1910. 


228      THE  HEART  AND  THE  AORTA 

much  blurred  on  radiological  examination,  when  in  point 
of  fact  there  is  an  aneurism.  It  is  necessary,  then,  to  at- 
tribute this  fact  to  the  fibrous  products  of  peri-aortitis, 
sufficiently  dense  to  disturb  the  clearness  of  the  arterial 
outline. 

(c)  Homogeneity  of  the  shadow.  If  we  compare  the 
image  of  an  aneurism  with  that  cast  by  a  gland  mass,  it  is 

j  noted  that  the  latter  presents  a  shadow  of  unequal  den- 
sity. It  is  formed  of  juxtaposed  patches  of  varying 
depth.  The  aortic  shadow  is  most  often  homogeneous. 
We  say  most  often,  because  in  some  cases  of  multiple  or 
irregular  sacs  zones  much  darker  than  the  rest  of  the 
vessel  are  found.  But  then  these  regions  correspond  to 
the  most  enlarged  parts  of  the  outline  in  direct  position  or 
to  the  most  marked  saliences  in  oblique  position. 

(d)  Pulsations.  One  of  the  most  important  character- 
istics of  aneurism  consists  in  the  arterial  beats  or  pulsa- 

J  tions  which  are  found  on  the  contour  of  the  shadow.  Still 
it  is  necessary  to  look  at  these  very  closely  and  to  differ- 
entiate the  pulsations  of  the  shadow  as  a  whole,  which  are 
sometimes  only  transmitted  pulsations,  from  those  of  the 
walls  which  take  the  form  of  an  undulation  along  the 
contour. 

But  even  if  the  pulsations  are  clearly  arterial,  the  con- 
clusion should  not  be  drawn  that  there  is  an  aneurism; 
the  same  image  may  be  given  by  a  tumor  of  the  medias- 
tinum. We  have  observed  two  cases  of  it.  In  the  first 
the  error  made  by  a  radiologist  and  by  ourselves  was  cor- 
rected only  by  the  development  of  the  symptoms.  In  the 
other  it  was  not  recognized  until  after  death,  and  autopsy 
revealed  an  enormous  gland  mass  in  the  mediastinum. 
The  lateral  outlines  of  the  mass  were  almost  parallel  and 
perfectly  linear.  The  aorta  passed  through  the  gland 
mass  and  it  was  that  which  caused  the  pulsations  during 
life. 

It  may  happen,  on  the  contrary,  that  the  pulsations  are 
lacking  on  the  contour  of  the   aneurisms.     Aneurisms 


ANEURISMS  OF  THE  THORACIC  AORTA      229 

often  have  been  found  entirely  without  movement,  either 
because  the  sac  was  filled  with  an  organized  clot  or  be- 
cause the  vascular  wall  was  infiltrated  with  atheromatous 
plaques. 

To  summarize,  therefore,  if  radioscopic  examination  is 
useful  in  diagnosing  aneurism  of  the  aorta,  it  is  still,  how- 
ever, open  to  mistakes.  The  most  perfect  radiographic 
evidence  always  requires  intelligent  interpretation. 

III.     DIAGNOSIS 

Although  the  indications  furnished  by  radiology  in  the 
examination  of  the  aorta  are  numerous  and  significant,  it 
does  not,  however,  follow  that  the  diagnosis  of  aneurism 
is  always  equally  easy.  To  be  sure,  it  presents  no  diffi- 
culty when  the  analysis  of  the  tracings  and  of  the  radio- 
graphic images  has  enabled  the  details  to  be  observed 
which  have  been  noted  in  the  course  of  this  study,  if  noth- 
ing else  has  intervened  to  spoil  the  interpretation.  But 
this  is  not  always  the  case;  in  some  circumstances  the 
shadows  have  not  the  same  clearness,  or  they  may  be 
deformed  by  secondary  shadows  with  irregular  contours, 
having  only  distant  and  indirect  relations  with  the  aorta, 
and  a  minute  analysis  is  then  necessary  to  distinguish 
what  belongs  to  this  vessel  and  what  is  due  to  lesions  of 
the  neighboring  organs. 

The  differential  diagnosis  of  aortic  aneurism  is  easily 
made  when  the  tracings  show  the  presence  of  an  isolated 
tumor  attached  to  the  vessel,  having  sharp,  clearly  defined 
contours,  the  whole  forming  an  opaque  shadow,  situated 
in  the  mediastinum,  with  perceptible  pulsations  on  the 
screen  which  can  be  due  only  to  a  vascular  tumor. 
These  signs  are  sufficient  to  eliminate  from  the  diagnosis 
a  whole  series  of  other  tumors  which  may  lie  in  the 
mediastinum  but  which  do  not  originate  in  the  aorta: 
such  as  lymphosarcomatous  tumors  at  the  level  of  the 
hilum  of  the  lung;  or  pulmonary  cancers  which  are  sit- 
uated in  the  full  parenchyma  and  which  also  extend  some- 


230      THE  HEART  AND  THE  AORTA 

times  toward  the  median  parts,  but  in  an  altogether  sec- 
ondary and  accessory  manner. 

The  question,  therefore,  seems  always  easy  of  solution ; 
but  it  is  very  necessary  that  it  should  present  itself  under 
all  circumstances  with  the  same  simplicity.  Aortic  aneur- 
ism may  be  complicated  with  peri-aortitis,  with  pericar- 
dial symphysis,  with  pleural  effusion,  all  lesions  capable 
of  obscuring  the  regions  usually  transparent,  of  obscur- 
ing the  shadow  produced  by  the  aneurism  itself,  of 
making  the  contours  diffuse,  and  therefore  making  the 
diagnosis  difficult. 

Inversely,  peribronchial  or  mediastinal  glands,  chronic 
infiltrations  or  tumors  of  the  pulmonary  parenchyma, 
pleural  effusions,  mediastinal  tumors,  etc.,  when  their 
extent  is  considerable,  may  invade  all  one  side  of  the 
thorax,  from  the  neck  to  the  diaphragm,  and  so  far  ob- 
scure the  cardio-vascular  contours  as  to  make  them  un- 
decipherable and  sometimes  mistaken  for  an  aneurism  of 
the  aorta  which  in  point  of  fact  does  not  exist.  In  these 
clinical  cases,  which  are  so  much  open  to  controversy, 
radiological  examination  is  useful,  not,  to  be  sure,  in 
deciding  between  two  doubtful  opinions,  but  in  offering 
elements  important  in  diagnosis. 

The  first  difficulty  to  surmount  is  to  recognize  or, 
rather,  to  mark  the  shadows  of  the  vessels,  the  second  is 
to  dissociate  them  from  superadded  abnormal  shadows. 
For  that,  investigation  will  have  to  be  made  of  the  differ- 
ent portions  of  the  vessel,  and  the  surface  examined,  then 
the  outline,  varying  the  angles  of  incidence.  After  this 
examination  has  verified,  on  the  screen  or  on  the  tracings, 
the  exact  contours  of  the  aorta,  the  diameters  will  be 
measured ;  then  the  entire  vessel  traced,  noting  the  points 
at  which  accessory  shadows  are  superadded.  The  latter 
will  be  marked  and  often  according  to  their  very  situa- 
tion the  probable  existence  of  an  aneurism  of  the  aorta 
will  be  considered.  If,  in  the  course  of  this  examination, 
the  aortic  outline,  at  first  normal,  is  suddenly  lost  in  a 


ANEURISMS  OF  THE  THORACIC  AORTA      231 

superadded  mediastinal  shadow  constituting  a  real  patho- 
logical salience  of  the  vessel,  the  diagnosis  of  an  aneurism 
will  be  justified.  The  conclusion  will  be  different  if  the 
shadow  presents  only  accidental  relations  with  the  vessel, 
and  a  mediastinal  tumor  is  more  likely.  It  will  be  unusual, 
then,  if  in  varying  the  position  of  the  patient  there  are 
not  found  in  certain  oblique  positions,  other  dense  masses 
of  the  same  form  probably  as  the  original  mass,  which 
will  exclude  the  idea  of  aneurism.  Such  dissociation, 
made  on  fluoroscopic  as  it  would  be  made  on  post-mortem 
examination,  is  often  very  difficult,  but  usually  if  the  pro- 
cedure is  methodical  a  diagnosis  is  arrived  at  which,  if  not 
final,  is  at  least  probable. 

A.       DIFFERENTIAL,     DIAGNOSIS      OF     AORTIC     ANEURISM      FROM 
OTHER    THORACIC     OR  INTRA-THORACIC     AFFECTIONS 

Malformations  of  the  skeleton.  The  error  here  is  rather 
exceptional;  usually,  indeed,  clinical  examination  of  the 
patient  shows  the  presence  of  such  malformations, 
notably,  deviations  of  the  vertebral  column. 

Pleuro -pulmonary  adhesions.  Lesions  of  the  pulmo- 
nary parenchyma.  Very  heavy  pleural  adhesions  of  the 
middle  region  of  the  thorax  rarely  lead  to  confusion 
because  of  the  irradiated  aspect  of  their  contours.  They 
constitute  simply  a  serious  interference  with  methodical  S 
examination.  Pulmonary  infiltrations,  which  give  such 
extensive  shadows  in  certain  cases  of  pulmonary  tuber- 
culosis, are  in  general  rather  easily  dissociated  from 
abnormal  shadows  of  the  aorta. 

Cancerous  masses,  syphilitic  gummata,  usually  have 
their  point  of  departure  at  the  level  of  the  pulmonary 
hilum.  When  they  increase  in  extent,  it  is  only  in  the 
form  of  prolongations  either  above  or  outside  the  clavicle, 
or  more  often  toward  the  base  of  the  lung. 

Interlobar  pleurisy.  Right  interlobar  pleurisy  with 
large  effusion  often  obscures  such  a  great  part  of  the 


232      THE  HEART  AND  THE  AORTA 

pulmonary  field  that  it  may  give  the  impression  of  a  vast 
aneurismal  sac.  But  the  diagnosis  of  this  form  of  pleu- 
risy is  facilitated  by  the  following  signs :  the  tumor  pre- 
sents a  somewhat  rounded  aspect  and  its  lower  contour 
lies  below  the  region  ordinarily  occupied  by-  aneurisms. 
Moreover,  it  is  usual  to  find  a  transparent  pulmonary 
band  between  the  tumor  and  the  diaphragm ;  finally,  suc- 
cessive examinations  will  show,  according  to  the  evolu- 
tion of  the  disease,  a  more  or  less  rapid  increase  of  the 
obscure  zone,  or,  on  the  contrary,  its  progressive  diminu- 
tion. 

If  the  effusion  is  only  moderate,  in  the  lateral  or  oblique 
positions,  its  shadow  is  seen  isolated  in  the  middle  of  the 
transparent  pulmonary  field  and  distinct  from  the  medi- 
astinal shadows. 

Cysts  of  the  lung.  Hydatid  cysts  lying  in  the  middle  or 
upper  portion  of  the  lung  may  be  mistaken  for  aneurism 
of  the  aorta.  The  same  is  true  of  large  dermoid  cysts  in 
elevated  position.  In  all  these  cases  it  is  essential  to 
establish  accurately  the  topography  of  the  shadows,  their 
position  and  their  characteristics  in  repeated  examina- 
tions, in  case  of  doubt,  some  days  or  some  weeks  apart. 
These  tumors  have  usually  a  clearly  circular  form  which 
differentiates  them  from  aneurisms.  Moreover,  the  modi- 
fications in  their  size  are  usually  more  rapid  than  those  of 
aneurism. 

In  other  cases,  however,  the  diagnosis  remains  doubt- 
ful, and  radiology  is  unable  to  establish  definitely  the 
position  and  nature  of  the  tumor  observed.  It  is  then 
that  laboratory  methods  should  be  resorted  to.  They  are 
especially  valuable  in  cases  of  hydatid  cysts,  as  shown  by 
Guedini,  Weinberg,  Parvu,  and  Laubry. 

Tumors  of  the  mediastinum.  Thoracic  adenitis,  lym- 
phoma, sarcoma,  lympho-sarcoma  often  show  considerable 
shadows  in  the  thorax  difficult  to  interpret.  Here  the 
data  must  be  applied  obtained  by  the  methods  used  in 
order  to  dissociate  the  vascular  shadows,  marking  the 


ANEURISMS  OF  THE  THORACIC  AORTA      233 

contours  in  all  positions,  and  to  determine  the  presence 
of  a  secondary  tumor,  the  existence  of  which  will  favor 
the  diagnosis. 

B.      DIFFEKENTIAL    DIAGNOSIS     OF     ANEURISM     OF     THE     AORTA 
FROM    DILATATIONS    OF    OTHER    VASCULAR    ORGANS 

The  presence  at  the  base  of  the  heart  of  sacciform  and 
expansile  tumor  does  not  clearly  signify  that  there  is 
aneurism  of  the  aorta.  Such  tumors  may  depend  either 
on  the  pulmonary  artery  (but  that  is  rarely  the  seat  of 
aneurisms)  or  on  great  dilatations  of  the  conus  arteriosus. 
There  have  also  been  described  dilatations  of  the  supe- 
rior vena  cava  which  might  be  mistaken  for  an  aneurism 
of  the  aorta.  Dilatation  of  the  left  auricle  and  especially 
that  of  the  left  appendage  may  also  cast  shadow  saliences 
like  those  of  aneurismal  sacs.  Grallavardin  has  recently 
reported  a  case. 

Radiological  diagnosis-  of  these  different  sanguine 
tumors  depends  on  their  topographic  position ;  most  often 
it  will  be  easy  enough  to  determine  their  exact  position 
and,  from  that,  their  origin. 

C.      ASSOCIATION     OF     ANEURISM     WITH     OTHER     LESIONS 

The  association  of  a  pleurisy  on  the  left  with  aortic 
aneurism  is  most  often  encountered ;  serous  effusion  then 
takes  place  in  the  large  pleural  cavity,  and  may  obscure 
the  left  contour  of  the  heart  as  far  as  the  base.  However, 
it  seldom  rises  higher  than  the  third  intercostal  space. 
If  the  aortic  sac  is  much  elevated,  the  contours  of  it  will 
be  seen  above  the  shadow  produced  by  the  effusion ;  if  it 
lies  on  the  descending  portion,  it  will  be  obscured  by  the 
shadow  of  the  effusion  which  will  make  it  impossible  to 
follow  the  inferior  contour  of  the  aneurism  and  to  esti- 
mate the  full  extent  of  it.  However,  even  in  these  cases, 
there  is  one  sign  which  persists  and  which  often  allows 
the  suspicion  of  an  aneurism :  that  is,  the  abnormal  devel- 


234      THE  HEART  AND  THE  AORTA 

opment  of  the  left  superior  arch.  In  these  especially 
doubtful  cases,  diagnosis  is  rendered  still  more  difficult 
by  the  fact  that  the  indications  can  only  be  made  use  of 
when  obtained  in  direct  position.  Indeed,  in  oblique  posi- 
tions, the  pleural  fluid  obscures  the  greater  part  of  the 
retro-cardiac  space,  so  that  it  is  impossible  to  say  whether 
or  not  another  shadow  exists  produced  by  an  aneurism. 

It  is  unusual  to  see  gland  masses  associated  with  an 
aneurismal  tumor.  But  these  masses  will  be  easily  recog- 
nized by  their  position  at  the  level  of  the  hilum,  by  the 
appearance  of  their  shadow  which  is  very  uneven;  they 
only  interfere  with  the  reading  of  the  outline  of  the 
vascular  walls. 

The  association  of  a  cardiac  affection  with  an  aortic 
aneurism  will  be  easily  demonstrated  by  radiological 
examination,  because  of  the  characteristics  peculiar  to 
each  of  the  diseases  of  the  heart,  which  have  been  studied 
in  the  preceding  chapters.  Very  often  the  heart  shows  no 
modification  of  volume  when  the  aorta  is  the  seat  of  a 
large  aneurismal  tumor.  Fluoroscopic  examination  or 
the  radiographic  image  will  easily  give  evidence  of  this ; 
but  in  other  circumstances  it  will  not  be  surprising  to 
find  an  enlargement  of  the  heart  coincident  with  a  valvu- 
lar lesion  of  the  aorta  or  with  other  cardiac  affections ;  the 
study  of  these  associated  lesions  has  only  a  limited  in- 
terest. 


CHAPTER  X 

LOCALIZATION    OF    WAR    PROJECTILES     IN    THE 
HEART    AND    PERICARDIUM 

WOUNDS  of  the  heart  from  projectiles  are  in  the 
majority  of  cases  rapidly  fatal.  However,  it  is  not 
unusual  to  have  patients  survive  with  fragments  of  metal 
in  the  cardiac  cavities  or  the  pericardium. 

According  to  a  review  which  we  have  made  of  medical 
literature,  eight  articles  have  been  published  of  foreign 
bodies  in  the  heart  not  extracted:  Finzi  (1915,  1  case) ; 
P.  Delbet  (February  2,  1916,  1  case) ;  Grandgerard 
(August  17, 1916,  1  case) ;  Ledoux-Lebard  (1916,  1  case) ; 
Lobligeois  (November  7,  1916,  1  case) ;  Ascoli  (January 
1,  1917,  1  case) ;  Lyle  (1917,  1  case) ;  Gilberti  (February, 
1917,  1  case). 

Thirteen  cases  in  France  which  were  surgically  treated 
have  been  published:  Beaussenat  (May,  1915,  April, 
1916,  2  cases) ;  Vouzelles  (November,  1915,  1  case) ;  Cou- 
teaud  and  Bellot  (December,  1915,  1  case) ;  Bichat  (May, 

1916,  1  case) ;  Dujarrier  (March,  1917,  1  case) ;  Chauvel 
and  Loiseleur  (March,  1917, 1  case) ;  Le  Fort  (May,  1917, 
1  case) ;  Fredet  (June,  1917,  1  case) ;  Hallopeau  (June, 

1917,  1  case) ;  Petit  de  la  Villeon— Juxta-cardiac  projec- 
tiles (April,  1916,  3  cases).  These  thirteen  surgical 
interventions  resulted  in  three  deaths  and  ten  cures. 

Other  cases  are  known,  the  reports  of  which  have  not 
yet  been  published.  Ledoux-Lebard  has  examined  seven 
cases  of  foreign  bodies  in  the  cardiac  walls,  three  of  which 
were  operated  on ;  three  cases  of  foreign  bodies  which  had 
penetrated  the  pericardium,  of  which  two  were  operated 
on.     Bouchacourt  has  radiographed  three  patients  with 


236      THE  HEART  AND  THE  AORTA 

projectiles  which  were  not  removed;  the  first,  a  bullet  in 
the  apex  of  the  heart,  another,  a  bullet  in  the  heart,  and 
the  third  a  splinter  in  the  pericardium  in  the  immediate 
vicinity  of  the  posterior  wall.  Maingot  has  radiographed 
a  case  with  a  bullet  in  the  left  ventricle,  extracted  by  Hart- 
mann,  and  a  foreign  body  in  the  heart  of  a  patient  of 
Pauchet's.  Finally,  we  have  examined  two  cases  of  pro- 
jectiles not  removed,  a  rifle  bullet  in  the  right  auricle  and 
a  piece  of  shrapnel  in  the  pericardium. 

Complete  statistical  data  cannot  be  compiled  now,  espe- 
cially of  cases  in  which  the  projectile  was  not  removed. 
Many  radiologists  have  observed  foreign  bodies  in  the 
heart  and  pericardium  without  publishing  their  observa- 
tions ;  on  the  other  hand,  due  to  the  frequent  transference 
of  the  wounded  and  the  frequent  examinations  made  of 
them,  the  same  patients  must  have  been  fluoroscoped  by 
several  specialists.  Not  until  after  the  war  will  the  Ser- 
vice de  Sante  be  able  to  compile  correct  statistics.  Of  the 
thirty-eight  cases,  however,  which  have  been  brought  to 
our  attention,  nineteen  cases  had  surgical  intervention. 
In  half  the  cases  the  projectiles  caused  disturbances  which 
necessitated  their  removal. 

These  disturbances  consisted  in  cardiac  pains,  in  at- 
tacks of  dyspnoea,  permanent  or  an  exertion.  The  aus- 
cultatory signs  were  insignificant  or  negative.  However 
serious  the  functional  disorders,  the  clinical  symptoms 
did  not  warrant  a  definite  diagnosis.  Only  radiological 
examination  gave  positive  evidence. 

The  importance  of  radio-diagnosis  is  therefore  appar- 
ent. But  though  it  is  relatively  easy  to  locate  a  foreign 
body  in  a  limb,  to  indicate  the  depth  in  relation  to  a  point 
on  the  skin,  or  by  a  bony  prominence,  the  localization  of 
a  projectile  in  the  heart  or  pericardium  meets  with  seri- 
ous difficulties.  These  difficulties  can  be  appreciated  by 
reviewing  the  unprecise  radiological  indications  which 
have  been  published  concerning  a  few  patients  that  have 
been  operated  on.    To  determine  the  presence  of  a  metal- 


LOCALIZATION  OF  WAR  PROJECTILES        237 

lie  body  in  the  heart  area  is  not  sufficient.  The  surgeon 
demands,  in  order  to  operate  intelligently,  that  the  radio- 
logical report  shall  be  full  and  precise. 

In  the  conference  of  November  10,  1915,  of  the  Societe 
de  Chirurgie,  this  question  was  discussed  and  Quenu  laid 
down  the  following  principles  : 

1.  In  all  cases  in  which  projectiles  are  deeply  situated 
in  limbs  or  in  an  organ,  simple  radiography  is  not  suffi- 
cient, it  only  gives  preliminary  information. 

2.  In  such  cases,  probing  for  a  projectile  is  not  per- 
missible until  after  localization,  and  this  localization 
ought  to  be  made  by  a  skilled  radiologist. 

3.  It  is  desirable  that  the  surgeon  should  have  at  his 
disposal  several  methods  of  research,  in  case  one  should 
fail. 

4.  It  is  necessary  that  the  search  for  foreign  bodies  be 
made  in  close  collaboration  by  surgeon  and  radiologist. 

The  best  method  of  localization  of  foreign  bodies  in  the 
cardiac  region  will  now  be  considered. 

I.     LOCATING  THE  PROJECTILE 

The  first  question  is  to  determine  whether  a  projectile 
is  in  the  region  of  the  heart,  and  this  is  done  by  making  a 
general  radioscopic  examination.  The  pulmonary  fields 
around  the  median  shadow,  the  cardio-diaphragmatic 
sinuses,  the  hila,  the  vessels  of  the  base  and  mediastinum, 
are  examined  in  order  to  find  out  first  the  condition  of  the 
regions  which  surround  the  heart  and  to  determine 
whether  pulmonary  lesions  exist  and  pleural  or  pericar- 
dial effusions.  In  the  latter  case,  the  obscurity  caused  by 
fluid  prevents  a  complete  investigation  or,  at  least,  a 
conclusion  being  drawn  from  the  examination,  if  no  pro- 
jectile shadow  can  be  demonstrated.  But  if  no  complica- 
tion exists,  the  examination  is  continued  by  inspecting  the 
surfaces  of  the  heart  in  the  direct,  oblique,  and  lateral 
positions. 


238      THE  HEART  AND  THE  AORTA 

Shrapnel  balls,  rifle  bullets,  or  fragments  of  some  size 
as  a  rule  are  readily  seen  on  the  screen.  It  is  not  so  with 
small  metallic  bodies.  They  may  not  attract  attention. 
In  Fredet's  case,  there  were  two  small  fragments,  one 
intra-pulmonary  which  was  noted  several  times,' the  other 
intra-cardiac  which  was  not  noticed  in  the  first  examina- 
tion. If  a  foreign  body  in  the  heart  is  suspected,  a  long 
and  careful  search  is  sometimes  necessary.  The  rays 
should  be  of  great  penetration.  A  hard  tube  with  an 
easily  adjustable  diaphragm  offers  great  advantages. 
Moreover,  in  the  course  of  the  examination,  the  intensity 
of  the  ray  is  varied  according  to  the  circumstances.  The 
rays  are  passed  over  the  entire  cardiac  area  and  the  least 
differences  in  the  homogeneity  of  the  shadow  is  studied; 
then  the  rays  are  moved  obliquely  in  order,  if  possible,  to 
make  them  pass  the  foreign  body  at  its  greatest  thickness, 
which  accentuates  the  shadow,  while  the  patient  is  placed 
at  various  angles  in  order  to  dissociate  the  superimposed 
shadows  of  the  thorax.  Sometimes  only  a  slight  move- 
ment of  the  tube  or  of  the  body  is  enough  to  show  the 
fragment  distinctly.  After  that  the  radiologist  does  not 
lose  sight  of  it  and  is  ready  to  make  precise  observations. 

When  the  projectile  is  free  in  a  cavity,  its  movement 
renders  it  indistinct.  By  radioscopy  we  can  observe  its 
exceedingly  rapid  movements.  Radiography  is  not  satis- 
factory, for  mobile  projectiles  give  extremely  vague  shad- 
ows or  leave  no  trace  on  the  radiogram.  However,  some 
radiographers  have  arrived  at  excellent  results  with 
apparatus  operating  at  one-fiftieth  of  a  second.  It  is 
always  useful  under  these  circumstances  to  objectify  the 
projectile  by  taking  a  radiogram.  This  is  indispensable 
in  cases  where,  in  spite  of  clinical  opinion,  radioscopic 
examination  remains  negative.  It  may  then  happen  that 
small  splinters,  not  seen  on  the  screen,  are  fixed  on  a 
good  radiogram.  This  test  is  always  necessary  in  order 
to  draw  a  conclusion. 

If  from  this  examination  the  evidence  is  positive,  the 


LOCALIZATION  OF  WAR  PROJECTILES        239 

next  step  is  to  locate  the  foreign  body  as  exactly  as  possi- 
ble. 

II.     METHODS  OF  LOCALIZATION 

The  purpose  of  localization  is  to  determine  the  depth 
at  which  a  projectile  lies  with  relation  to  a  determined 
point  on  the  skin.  If  this  has  been  fixed  at  the  place  where 
incision  should  be  made,  the  surgeon  knows  in  operating 
at  what  distance  and  in  what  direction  he  will  encounter 
the  foreign  body. 

The  calculation  of  the  depth  is  obtained  by  a  number  of 
methods  which  depend,  for  the  most  part,  on  the  geo- 
metric relations  of  similar  triangles.  The  construction 
of  these  triangles  is  based  on  shifting  the  tube  a  known 
distance.  The  figure  of  the  projections  is  completed 
either  by  means  of  instruments  or  by  means  of  drawings, 
diagrams,  or  stereoscopic  images. 

Instrumental  methods  are  represented  by  the  Hirtz 
compass  and  others  derived  from  it.  During  the  opera- 
tion an  indicator  marks  the  direction  and  the  depth  of 
the  projectile.  It  is  evident  that  the  mobility  of  the  region 
to  be  explored  causes  technical  errors  and  difficulties. 
The  extent  of  the  movements  of  the  thorax  and  the  res- 
piratory displacements  of  the  heart  are  not  the  same.  If 
a  mark  is  made  on  the  skin,  corresponding  to  a  zone  of 
the  maximal  oscillations  of  the  foreign  body,  unexpected 
modifications  of  the  respiratory  rhythm  during  anesthe- 
sia may  render  it  unsafe.  In  the  course  of  the  operation, 
the  drawing  up  of  the  heart  into  the  surgical  opening 
changes  momentarily  all  the  surrounding  relations.  So 
the  use  of  compasses  does  not  seem  strictly  advisable 
in  surgery  of  the  heart. 

But  that  does  not  imply  that  all  measurement  of  depth 
should  be  rejected.  It  is  advisable  to  try  it  wherever 
possible.  Among  the  most  rapid  methods  are  those  of 
Ropiquet,  Haret,  Hirtz-Gallot,  Aime,  Barjon,  Casel,  etc. 
However  approximate  the  indications  may  be,  there  will 


240      THE  HEART  AND  THE  AORTA 

still  remain,  however,  an  interesting  element  of  individual 
judgment.  It  lias  been  seen  that  the  index  of  depth  of  the 
left  ventricle  in  normal  subjects  varied  from  7  to  14  milli- 
meters. The  tables  of  calculation  show  that  these  indices 
correspond  experimentally  to  a  depth  of  10  to  12  centi- 
meters for  the  portion  of  the  posterior  wall  tangent  to  the 
oblique  ray.  The  double  measurement  of  the  depth  of  the 
heart  and  the  depth  of  the  projectile,  on  condition  that 
the  latter  is  not  very  far  from  the  zone  of  the  apex,  de- 
termines whether  it  is  in  the  anterior  or  in  the  posterior 
segment  of  the  organ,  that  is  to  say,  in  the  right  or  in  the 
left  ventricle. 

The  methods  of  localization  are  not  of  interest  except 
when  they  help  to  locate  the  projectile  anatomically.  So 
it  is  this  particular  point  of  view  that  the  radiologist 
ought  to  keep  in  mind. 

III.     ANATOMICAL  LOCALIZATION 

It  is  a  question  of  finding  out  whether  the  projectile  is 
in  the  pericardium  or  in  the  heart  and  in  which  cavity  of 
the  heart. 

Peojectiles  in  the  Pekicakditjm.  When  the  wound  is 
recent,  the  hemo-pericardium  interferes  considerably  with 
the  examination  and  it  may  be  impossible  to  give  an 
opinion.  If  the  amount  of  the  effusion  does  not  make  the 
projectile  invisible,  the  localization,  though  very  difficult, 
may  be  conclusive.  As  a  rule,  the  foreign  body,  after 
having  penetrated  the  folds  of  the  pericardium,  falls  into 
the  bottom  of  the  sac  and  is  seen  in  the  inferior  diaphrag- 
matic portion  of  the  shadow.  But  if,  for  some  special 
reason,  the  piece  of  metal  remains  in  the  upper  parts,  if 
it  is  fixed  there  by  adhesions,  it  is  found  by  signs  very 
much  like  those  of  projectiles  lodged  in  the  walls  of  the 
heart.  We  have  not  found  observations  which  enable  us 
to  study  this  question  in  detail. 

When  the  effusion  has  been  reabsorbed  and  the  peri- 
cardial folds  have  become  transparent  again,  the  locali- 


LOCALIZATION  OF  WAR  PROJECTILES        241 

zation  of  the  projectile  in  the  inferior  part  of  the  sac  is 
easily  made.  A  number  of  characteristic  signs  are  noted ; 
those  that  have  been  found  in  the  course  of  an  observation 
of  this  kind  are  presented  here : 

A  case  of  a  gunner  in  the  first  artillery,  with  a  shrapnel 
shell  seen  in  direct  anterior  position,  on  the  inferior  con- 
tour of  the  right  ventricle,  at  the  level  of  the  left  outline 
of  the  vertebral  column  (Fig.  174).     It  lay  about  half 


Fig.  174.  SHEAPNEL  BALL  IN  THE  PEEICAEDIUM,  IN  THE  LOWEE 
PAET  OF  THE  HEAET 


way  over  this  line.  It  was  separated  from  the  central 
portion  of  the  diaphragm  by  a  transparent  band  which 
enlarged  during  inspiration.  In  lateral  position,  the 
projectile  was  under  the  ventricular  mass,  3.5  cm.  from 
the  anterior  thoracic  wall  (Fig.  175). 

The  markings  gave  the  following  result:  projectile 
lodged  3.5  cm.  deep  from  the  inferior  sternal  wall,  on  an 
antero-posterior  line  passing  to  the  lower  part  of  the 
right  heart  and  tangent  to  the  left  side  of  the  vertebral 
column. 

A  study  of  the  movements  of  the  projectile  was  made 
to  determine  whether  the  ball  was  adherent  to  the  ven- 
tricular wall  or  lay  in  the  pericardium. 


242      THE  HEART  AND  THE  AORTA 

These  movements  were  of  two  sorts:  (1)  pulsations, 
(2)  respiratory  displacements. 

The  pulsations  were  synchronous  with  those  of  the 
heart,  but  they  had  a  much  greater  amplitude.  They 
could  be  studied  in  right  anterior  oblique  position  at  20 
degrees  (Fig.  176).    They  spread  vertically  with  a  total 


Fig.  175.     SAME  CASE,  IN  LEFT  LATEEAL  POSITION 


Fig.  176.     SAME  CASE,  IN  EIGHT  ANTEEIOE  OBLIQUE  POSITION 

AT  20  DEGEEES 


LOCALIZATION  OF  WAR  PROJECTILES        243 

excursion  of  8  mm.,  4  mm.  up,  and  4  mm.  down,  which 
showed  that  it  was  a  question  of  transmitted  pulsations. 


Fig.  177.     SAME  CASE,  IN  EIGHT  ANTEEIOE  OBLIQUE  POSITION 
Bespiratory  movements  of  the  heart,  the  diaphragm,  and  the  projectile. 


The  respiratory  displacements  indicated  in  Fig.  177 
(right  anterior  oblique,  45  degrees),  were  in  the  same 
direction  but  more  extended  than  those  of  the  heart,  also 
in  the  same  direction  but  less  extended  than  those  of  the 
diaphragm. 

The  anatomical  localization,  consequently,  was  as  fol- 
lows :  projectile  lodged  in  the  pericardium,  in  the  vicinity 
of  the  ventricular  wall. 

Intba-caediac  Peojectiles.  The  cavities  most  often 
affected  are  the  right  cavities,  ventricle  and  auricle,  by 
reason  of  the  superficial  position  which  they  occupy  in 
relation  to  the  anterior  surface  of  the  thorax.  The  left 
ventricle  seems  to  be  less  often  affected. 

To  locate  a  projectile  in  one  of  these  cavities,  it  is  well 
to  consider  successively  the  topography  of  the  region 
involved  and  the  movements,  pulsations ,  or  displacements 
of  the  metallic  bodies. 

The  topographic  indications  furnish  data  which  are 


244 


THE  HEART  AND  THE  AORTA 


recognized  by  the  projection  of  the  heart  shadows  in  the 
different  positions. 

The  right  ventricle  occupies,  in  the  frontal  position,  the 
median  part  of  the  cardiac  shadow,  between  a  rather  nar- 
row band  along  the  edge  of  the  left  ventricle  and  a  trian- 
gular surface  with  the  point  down,  which  belongs  to  the 
right  auricle.  But  if  the  middle  zone  corresponds  in  front 
to  the  right  ventricle,  it  corresponds  behind  to  the  left 
ventricle.  It  is  not  enough,  then,  to  prove  the  presence  of 
a  projectile  in  this  region  in  order  to  locate  it.    It  is  just 


Fig.   178.     EIFLE  BALL  IN  THE  WALL  OF  THE  EIGHT  AUEICLE 


here  that  measurement  of  depth  is  useful.  It  is  desirable 
to  make  this  before  every  intervention,  since  only  opera- 
tion can  verify  this  question,  for  the  measurements  made 
on  the  dead  body  are  not  comparable  with  the  relations  in 
the  living  body.  In  the  case  reported  by  Chauvel  and 
Loiseleur,  the  rifle  ball  had  been  plotted  6.5  cm.  in  depth, 
rather  near  the  apex.  Eadiological  localization  supposed 
the  projectile  encysted  in  the  right  side  of  the  heart.  In 
point  of  fact,  that  is  where  the  surgeon  found  it. 

A  manipulation  which  may  show  which  ventricle  is 
affected  consists  in  placing  the  patient  in  left  anterior 
oblique  position  so  that  the  normal  ray  passes  through 
the  major  axis  of  the  heart.     An  intense  illumination 


LOCALIZATION  OF  WAR  PROJECTILES        245 

allows  us  to  see  the  foreign  body,  and  according  as  it 
occupies  the  anterior  or  the  posterior  segment,  to  plot 
approximately  its  position. 

The  right  auricle  is  outlined  in  the  right  hemithorax 
and  we  may  consider  as  properly  belonging  to  it  the  area 
defined  on  the  outside  by  the  right  outline  of  the  heart 
as  far  as  the  diaphragm,  and  on  the  inside  by  a  schematic 
line  from  the  cardio-hepatic  angle  to  the  median  part  of 
the  base  of  the  organ. 


Fig.  179  Fig.  180 

Fig.  179.     SAME  CASE,  IN  LEFT  POSTERIOR  OBLIQUE  POSITION 
Fig.  180.     SAME  CASE,  IN  RIGHT  POSTERIOR  OBLIQUE  POSITION 

It  is  in  this  region  that  projectiles  in  this  cavity  are 
seen.  Fig  178  is  an  example ;  it  is  of  a  patient  with  a  rifle 
ball  in  the  wall  of  the  right  auricle.  In  left  posterior 
oblique  position,  the  right  auricle  is  outlined  in  the  lower 
two-thirds  of  the  retro-cardiac  clear  space  (Fig.  179) ;  in 
right  posterior  oblique  position  this  auricle  corresponds 
to  the  median  portion  of  the  image  of  the  heart. 

It  is,  in  point  of  fact,  in  this  region  that  we  find  the 
ball  (Fig.  180). 

Projectiles  are  animated  by  variable  movements  ac- 


246      THE  HEART  AND  THE  AORTA 

cording  as  they  are  free  in  the  cavities  or  imbedded  in  the 
walls. 

In  the  first  case,  they  show  whirling  movements  which 
are  absolutely  characteristic.  Lobligeois  describes  these 
movements  in  a  patient  he  examined.  It  was  a  question 
of  a  shrapnel  ball  lodged  in  the  left  ventricle.  "At  the 
end  of  diastole,  the  ball  rested  on  the  inferior  border  of 
the  heart,  near  the  apex;  when  systole  intervened,  it 
veered  rapidly  from  left  to  right  (of  the  patient)  along 
the  lower  border,  evidently  struck  against  the  inter- 
ventricular partition  and  followed  that  from  below  up- 
ward in  vertical  direction.  It  thus  arrived  at  the  most 
elevated  point  of  the  ventricle,  but  against  the  right  side 
of  the  ventricle.  That  was  the  end  of  the  systole.  It 
remained  there  an  instant  immobile,  then  redescended 
slowly,  from  above  downward  and  from  right  to  left, 
during  diastole  to  resume,  after  that,  the  position  near 
the  apex  of  the  heart  and  begin  again  a  new  evolution.  It 
described,  then,  a  right  angle  triangle  in  which  the  right 
angle  might  have  been  a  little  rounded;  during  the  sys- 
tole it  ran  rapidly  over  the  two  adjacent  sides  of  the  right 
angle  and  descended  slowly  during  the  diastole  along  the 
hypotenuse." 

Barret  has  noted  in  a  case  with  a  projectile  in  the  right 
ventricle  whirling  movements  of  extreme  rapidity.  He 
compares  the  agitation  of  the  ball  to  that  of  the  slug  in  a 
sleighbell. 

These  movements  are  also  observed  in  the  right  auricle. 
In  the  case  of  Ledoux-Lebard,  the  shrapnel  ball  described 
continuously  a  sort  of  ellipse  with  a  major  vertical  axis 
of  about  two  centimeters. 

The  whirling  movements  are  sometimes  intermittent. 
Ascoli  observed  a  shrapnel  ball  in  the  right  auricle  which 
described  a  rhythmic  pendular  oscillating  movement  in 
the  transverse  direction.  Every  four  or  five  oscillations 
there  appeared  a  sudden  whirling  movement,  then  the 
rhythmic  movement  was  resumed.    Ascoli  noted  that  the 


LOCALIZATION  OF  WAR  PROJECTILES        247 

whirling  increased  during  inspiration,  doubtless  because 
of  the  increase  of  the  intra-thoracic  negative  pressure 
which  favored  the  afflux  of  the  blood  toward  the  right 
auricle. 

These  movements  are  considered  characteristic  of 
bodies  in  cavities  since  the  first  observation  of  Trendelen- 
burg. But  according  to  Ascoli  they  can  be  observed  in 
cases  in  which  the  projectile  is  lodged  in  the  pericardium. 
Finally,  it  should  be  remembered  that  not  all  free  intra- 
cardiac projectiles  are  animated  by  the  same  movements. 
In  a  case  noted  by  Beaussenat  a  small  fragment  of  shell 
showed  regular  movements  of  slight  amplitude  synchro- 
nous with  the  beats  of  the  heart;  operation,  however, 
showed  that  it  lay  in  the  right  ventricle  where  it  was  free. 

When  the  foreign  body  is  immobilized  against  the  walls 
of  the  heart,  its  movements  are  those  which  it  would  have 
if  it  adhered  there  closely  or  if  it  were  enclosed  in  the 
myocardium. 

These  movements  are  those  of  the  walls  of  the  heart. 
They  consist  of  respiratory  displacements,  static  displace- 
ments, and  rhythmic  pulsations. 

The  respiratory  displacements  lift  the  projectile  at  the 
same  time  as  the  organ  during  expiration  and  lower  it 
during  inspiration.  Static  displacements  deviate  it  one 
side  or  the  other  of  the  median  line  during  the  inclination 
of  the  body  to  the  right  or  to  the  left. 

The  rhythmic  pulsations,  synchronous  with  the  pulsa- 
tions of  the  heart,  offer  special  characteristics  according 
to  the  region  in  which  they  are  observed.  Along  the  left 
outline  they  take  an  almost  vertical  direction,  from  above 
downward,  during  systole.  At  the  apex,  the  movement  of 
systolic  retraction  is  from  below  upward  and  from  with- 
out inward,  following  the  longitudinal  axis  of  the  heart. 
At  the  base  of  the  right  ventricle  the  systolic  pulsations 
go  from  right  to  left  of  the  patient  in  a  direction  parallel 
to  the  inferior  outline  of  the  heart.  On  the  anterior  sur- 
face of  the  heart   (right  ventricle)   they  spread  trans- 


248      THE  HEART  AND  THE  AORTA 

versally.  In  the  walls  of  the  right  auricle  the  movements 
of  retraction  are  clearly  presystolic  and  in  a  transverse 
direction.  Finally,  whatever  the  point  is  that  is  exam- 
ined, the  amplitude  of  the  oscillations  of  the  projectile  is 
equal  to  that  of  the  pulsations  of  the  walls. 

The  localization  of  intra-cardiac  or  pericardiac  projec- 
tiles necessitates,  as  will  be  seen,  a  series  of  delicate  and 
often  difficult  examinations.  It  may  be  well  to  cite  here 
as  an  example  the  observation  of  Digne  in  the  case  of 
Fredet.  The  radio-diagnosis  was  as  follows :  "  Fragment 
the  size  of  a  pea,  clearly  pulsatile,  at  the  base  of  the  left 
hemithorax,  slightly  to  the  left  of  the  median  line,  intra- 
cardiac, situated  in  the  right  ventricle  probably  close 
against  the  anterior  wall,  nearer  to  the  inferior  contour 
than  to  the  longitudinal  diameter  of  the  cardiac  image. ' ' 
Operation  showed  that  the  fragment  was  enclosed  in  the 
wall  of  the  right  ventricle  two  fingerbreadths  from  the 
apex  and  a  good  fingerbreadth  from  the  inter-ventricular 
groove. 

Radiology,  therefore,  offers  a  certain  method  of  investi- 
gation, it  localizes  by  radioscopy  the  exact  anatomical 
position  of  projectiles  and  is  an  essential  aid  to  their 
surgical  removal. 

IV.     EXTRACTION    OF    PROJECTILES    UNDER    FLUOROSCOPIC 

GUIDANCE 

The  radioscopic  apparatus  for  the  extraction  of  foreign 
bodies  consists  of  a  base,  which  supports  the  tube,  placed 
under  a  wooden  table.  The  source  of  the  exciting  current 
may  be  in  the  operating  room,  or,  if  possible,  in  a  neigh- 
boring room.  Certain  surgeons  operate  by  artificial  light, 
red,  violet,  green,  or  yellow,  which  enables  them  to  see 
at  the  same  time  as  the  roentgenologist  the  fluoroscopic 
image  of  the  projectile.  The  use,  which  is  becoming  more 
and  more  common,  of  the  "bonnet"  fluoroscope,  allows 
the  surgeon  to  operate  in  daylight;  he  is  guided  by  the 


LOCALIZATION  OF  WAR  PROJECTILES        249 

radiologist  who  examines  intermittently  the  position  of 
the  foreign  body. 

Intervention  under  fluoroscopic  guidance  offers  the 
following  advantages : 

Before  incision,  a  rapid  marking  made  on  the  skin  of 
the  patient  in  the  operating  position  indicates  the  zone 
in  which  the  surface  projection  of  the  foreign  body  is. 

During  the  search  for  the  projectile,  radioscopy  gives 
the  surgeon  perfect  security,  for  it  permits  him  to  verify 
his  own  impressions.  When  a  pericardial  effusion  has 
been  evacuated  and  the  finger  exploring  the  sac  does  not 
encounter  the  projectile,  an  inspection  with  the  "bonnet" 
gives  immediate  information  as  to  its  presence  or  its 
absence.  If  it  is  a  question  of  extracting  an  intra-cardiac 
foreign  body,  the  surgeon,  before  making  an  incision  in 
the  wall,  examines  whether  the  form  of  the  mass  which  he 
holds  between  his  fingers  corresponds  to  the  projectile. 
Finally,  if  the  projectile  becomes  displaced  (and  cases 
of  unexpected  migration  have  been  noted),  radioscopy  is 
of  great  value. 

The  last  stage  of  the  operation  is  also  facilitated  by  the 
fluoroscope.  The  roentgenologist  guides  the  operator  in 
taking  the  projectile  with  the  forceps  and  after  the  re- 
moval he  searches  for  any  fragments  of  metal  that  may 
remain. 

Radiology,  therefore,  plays  a  part  of  primary  impor- 
tance in  diagnosing,  localizing  war  projectiles  in  the 
heart,  and  facilitating  the  different  stages  of  surgical 
extraction. 


BIBLIOGRAPHY  RELATING  TO  THE  LOCALIZATION 
OF   PROJECTILES 

Beaussenat.     Plaie  du  cceur  par  eclat  de  grenade.     (Academie 

de  Medecine,  4  mai,  1915.    Academie  des  Sciences,  10  avril, 

1916.) 
Finzi.    Case  of  a  bullet  in  the  heart  muscle.     {The  Journal  of  the 

Roentgen  Society,  1915,  No.  43,  pi.  V,  and  No.  44,  pi.  VIII.) 
Vouzelles.     Eclat  de  grenade  libre  dans  le  ventricule   droit. 

(Bulletins  et  Memoires  de  la  Societe  de  chirurgie,  10  novem- 

bre,  1915.    Discussion.) 
Couteaud  et  Bellot.     Extraction  d'une  balle  dans  l'oreillette 

droite  du  cceur.     (Revue  de  chirurgie,  decembre,  1915.) 
P.  Delbet.     Projectile  loge  dans  la  paroi  posterieure  du  cceur. 

(Societe  de  chirurgie,  7  fevrier,  1915.) 
Petit  de  la  Villeon.    Trois  cas  de  projectiles  juxta-cardiaques 

extraits  par  trois  procedes  differents.    (Societe  de  chirurgie, 

12  avril,  1916.) 
Bichat.    Extraction  d'un  eclat  d'obus  du  ventricule  droit.     (So- 
ciete de  chirurgie,  3  mai,  1916.) 
Grandgerard.     Migration  rapide  dans  le  reseau  veineux  d'une 

balle  de  shrapnell  libre  dans  l'oreillette  droite.      (Ref.  in 

Presse  Medicate,  17  aout,  1916.) 
Ledoux-Lebard.    Balle  de  shrapnell  libre  dans  l'oreillette  droite. 

(Journal  de  Radiologic,  1916,  No.  I,  p.  35.) 
Barret,  Localisation  radiologique  d'un  projectile  intra-cardiaque 

libre  et  mobile  dans  le  ventricule  droit.     (Journal  de  "Radio- 
logic, 1916,  I.) 
Lobligeois.     Une  balle   de  shrapnell  libre   dans  le  ventricule 

gauche.     (Academie  de  medecine,  7  novembre,  1916.) 
Ascoli.    Projectile  libre  dans  l'oreillette  droite,  apres  passage  a, 

travers  la  veine  cave  inferieure.      (Le  Malattie  del  cuore, 

ler  Janvier,  1917.) 


BIBLIOGRAPHY  251 

H.  Lyle.    Migration  d  'un  fragment  d  'obus  de  la  veine  f emorale 

droite  jusqu'au  ventricule  droit  du  cceur. 
Gilberti.     Courte  note  sur  un  cas  de  projectile  dans  le  coeur. 

{Le  Malattie  del  cuore,  fevrier,  1917.) 
Dujarrier.    Balle  dans  la  paroi  anterieure  du  ventricule  droit. 

Ablation.    Guerison.     {Societe  de  chirurgie,  14  mars,  1917.) 
Chauvel  et  Loiseleur.     Plaie  du  cceur  par  balle.     Projectile 

enkyste  dans  le  bord  droit  du  cceur.    Extraction  sous  rayons. 

Guerison.     {Societe  de  chirurgie,  14  mars,  1917.) 
Hartmann.    Rapport.     {Societe  de  chirurgie,  14  mars,  1917.) 
Le  Fort.    De  l'extraction  des  projectiles  de  la  face  posterieure 

du    cceur     {cardiaques    et    juxta-cardiaques) .       {Bulletin 

Academ.  de  Medecine,  15  mai,  1917.) 
Hallopeau.     Plaie  du  coeur  par  eclat  d'obus  enkyste  dans  la 

pointe.    Extraction  sous  rayons.    Guerison.     {Bulletin  de  la 

Societe  de  chirurgie,  seance  du  30  mai,  1917,  p.  1,  213.) 
Fredet.     Extraction  d'un  fragment  d'obus  loge  dans  la  paroi 

anterieure  du  ventricule  droit.    Guerison.     {Societe  medico- 

chirurgicale  militaire  de  la  14e  Region.     5  juin,  1917.    In 

Ly  on-medical. ) 


INDEX 


Adhesions  to  anterior  thoracic 
wall,  184 

of  apex  of  heart,  183 

of  base  of  heart,  183 

in  diaphragmatic  region,  184 

pericardial,  data  relating  to 
existence  of,  169 

pericardial,  partial,  with  car- 
diac symphysis,  165 

site  of,  183 
Affections  of  heart,  congenital, 
115 

of  the  pericardium,  161 

valvular,  75 
Anatomical  localization,  240 
Aneurism,    aortic,    differential 
diagnosis    of:    from    dila- 
tation   of    other    vascular 
organs,  233 

aortic,  differential  diagnosis 
of:  from  other  thoracic 
or  intra-thoracic  affections, 
231 

associated  with  other  lesions, 
233 

diagnosis  of  (aortic),  229 

shadows,  general  appearance 
of,  223 
Aorta  in  the  normal,  192-204 

in    pathological    state,    204- 
216 
Aortic  insufficiency,  102 

insufficiency,  arterial,  108 


Aortic    iiisufficiency,    endocar- 
ditic,  102 

pulsations,  201 

shadow,  density  of,  201 

stenosis,  111-114 

stenosis,  congenital,  132 
Aortitis,  192 
Apex  of  heart,  76,  172 

in  frontal  position,  23 
Arc,  left  median,  76 
Arhythmia,  chronic,  156 
Arhythmic  heart,  155 
Artery,  pulmonary,  simple  ste- 
nosis of,  123-127 
Asystolism  and  cardiac  insuffi- 
ciency, 159 
Auricle,  left,  71 

right,  72 

Basedow's  disease,  152 
Boulitte's  goniometer,  39 

Cardiac  dilatation,  148 

ectopia,  134 

hypertrophy  and  dilatation, 
142 

hypertrophy  in  the  aged,  146 

insufficiency  and  asystolism, 
159 

symphysis  and  partial  ad- 
hesions of  pericardium, 
165 


254 


INDEX 


Cardiograms,  interpretation  of 
and  comparison  with  per- 
cussion tracings,  80 

Cinemato-radiography,  36 

Comparison  of  palpation  and 
percussion  with  radiologi- 
cal findings,  185 

Congenital  affections  of  heart, 
115 
aortic  stenosis,  132 

Contours   of  heart  in   frontal 
position,  20 
of  heart,  right,  77 

Cysts  of  the  lung,  232 

Density  of  aortic  shadow,  201 
Depth,     ventricular     develop- 
ment determined  by,  53 
Destot's  orthodiagraph,  8 
Diameters  of  heart,  25-33,  77 
Diaphragm,  movements  of,  176- 
180 
position    during    forced    ex- 
piration, 35-36 
position    during    forced    in- 
spiration, 35-36 
Diaphragmatic    region,     adhe- 
sions in,  184 
Dilatation,  cardiac,  148 
Displacements  due  to  respira- 
tion, 34 
of  heart  outlines,  171 
Dropping  heart,  51 

Ectopia,  cardiac,  134 
Effusions,  pericardial,  161 
Endocarditic      aortic      insuffi- 
ciency, 102 
Extraction  of  projectiles  under 
fluoroscopic  guidance,  248 


Functional  mitral  insufficiency, 
93 

Goniometer  of  Boulitte,  39 

Heart,  adhesions  of  apex,  183 

adhesions  of  base  of,  183 

apex,  76,  172 

apex  in  frontal  position,  23 

arhythmic,  155 

congenital  affections,  115 

contours  in  frontal  position, 
20 

diameters  of,  25-33,  77 

dropping  type,  51 

image  in  frontal  positions, 
18-38 

image  in  oblique  positions, 
38-47 

mobility  of,  33 

modifications  affecting  whole 
volume,  61-63 

outline,  180 

outlines,  displacement  of, 
174 

partial  modification  of  vol- 
ume, 63-74 

position  during  forced  expi- 
ration, 35-36 

position  during  forced  in- 
spiration, 35-36 

pulsation,  36 

radiological  outline  in  cer- 
tain pathological  condi- 
tions not  resulting  from 
valvular  lesions,  142 

radioscopic  examination  of, 
58-59 

right  contour  of,  81-82 

rules  for  radiological  exami- 
nation of,  58-60 


INDEX 


255 


Heart  shadow  in  pathological 
state,  61-74 
shadow,  measurements  of,  23 
shadow,  normal,  16-60 
Horizontal  type  of  heart,  50 
Hypertrophy,   cardiac,   in   the 
aged,  146 
cardiac  and  dilatation,  142 

Instantaneous  radiography,  3 
Insufficiency,  aortic,  102-111 
aortic,  arterial,  108 
aortic,  endocarditic,  102 
cardiac  and  asystolism,  159 
mitral,  87-96 
mitral,  functional,  93-96 
Interlobar  pleurisy,  231-232 
Inter-ventricular     perforation, 

115-122,  127 
Intra-cardiac   projectiles,    243- 

248 
Inversion  of  the  viscera,  total, 
134-141 

Lesions  associated  with  aneu- 
rism, 233-234 
valvular,  75 
Localization,    anatomical,    240- 
248 
methods  of,  239-240 
of  war  projectiles  in  heart 
and  pericardium,  235-249 
Lung  cysts,  232 

Median  arc,  left,  76 
Mediastinitis,  posterior,  185 
Mediastinum,   tumors  of,    232- 

233 
Method,  orthodiagraphic,  7-10 
orthodiascopic,  5-7 


Method,  radiographic,  2-4 
radiological,  2-15 
radioscopic,  4-11 
Mitral  disease,  96-102 
insufficiency,  87-96 
insufficiency,  functional,  93- 

96 
stenosis,  simple,  75-87 
Mobility  of  the  heart,  33-34 
Modifications    affecting    whole 
heart,  61-63 
of  heart  volume,  partial,  63- 
74 
Movements  of  the  diaphragm, 
176-180 

Normal  aorta,  192-204 
Normal  heart  shadow,  16-60 
Normal  radioscopy,  4 

Oliver's  sign,  51 
Orthodiagraph  of  Destot,  8 
Orthodiagraphy,  7-10 
Orthodiascopy,  5-7 

Palpation,  compared  with  ra- 
diological findings,  185 

Pathological  aorta,  204-215 
condition   of   heart   shadow, 
61-74 

Percussion  compared  with  ra- 
diological findings,  185 

Perforation,    inter-ventricular, 
115-122,  127 

Pericardial  adhesions,  data  re- 
lating to  existence  of,  169 

Pericardium,  affections  of,  161 
localization    of   war   projec- 
tiles in,  235-249 

Pleurisy,  interlobar,  231-232 


256 


INDEX 


Position,  direct  anterior,  16 
direct  posterior,  17 
dorsal,  17 

left  anterior  oblique,  18,  45 
left  lateral,  18 

left  posterior  oblique,  18,  43 
prone,  17 

right  anterior  oblique,  18,  44 
right  lateral,  18 
right  posterior   oblique,    18, 

44 
seated,  18 
upright,  17 
Positions,  direct,  16-18 
lateral,  18,  47 
oblique,  18,  82-87 
Posterior  mediastinitis,  185 
Projectiles,  extraction  of,  under 
fluoroscopic  guidance,  248 
intra-cardiac,  243-248 
localization  of  in  heart  and 
pericardium,  235-249 
Pulmonary  artery,  simple  ste- 
nosis of,  123 
stenosis   of,    with   inter-ven- 
tricular  perforation,    115- 
122 
Pulsation  of  heart,  36 
aortic,  201 

Respiration,  displacements  due 

to,  34 
Respiratory  outline,  181 
Rules  for  radiological  examina- 
tion of  heart,  58-60 

Stenosis,  aortic,  111-114 
aortic,  congenital,  132 


Stenosis  of  pulmonary  artery 
with  inter-ventricular  per- 
foration, 115-122 
of  pulmonary  artery,  simple, 

123-126 
simple  mitral,  75-87 
Symphysis,  cardiac,  with  par- 
tial adhesions  of  pericar- 
•   dium,  165 

Technic  of  orthodiagraphy, 
teleradioscopy  and  tele- 
radiography, 11-12 

Teleradiography,  3-4,  13-14 

Teleradioscopy,  12,  15 

Thoracic  aorta,  aneurisms  of, 
216-235 

Thoracic  wall,  anterior,  adhe- 
sions to,  184 

Time  radiography,  2 

Transverse  diameter  of  heart, 
26 

Tumors  of  mediastinum,  232- 
233 

Valvular  affections,  75-114 
Variations      of      physiological 

form  of  heart,  50-53 
Ventricle,  left,  6Q 

right,  68 
Ventricular     development     in 
depth,  53-58 
outline,  left,  76 
volume,     determination     of, 
total,  64-66 
Vertical  type  of  heart,  50 
Viscera,  total  inversion  of,  134- 
141 


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